CA News - June 2019

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news NEWSLETTER OF CHIROPRACTIC AUSTRALIA

JUNE 2019

VOLUME 2 NUMBER 2

Bobby Maybee Interview Chiropractic History Journal Club Articles Vale John Sweaney


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FROM THE PRESIDENT

Professor Rod Bonello

BSC(SYD), DO, DC(SCC), MHA(UNSW), FRCC

UPDATE ON THE INDEPENDENT REVIEW INTO CHIROPRACTIC MANIPULATION OF CHILDREN UNDER 12 YEARS In our last issue I reported on the establishment of an investigation into the appropriateness of chiropractic paediatric care following adverse public reaction to a web page video of a chiropractor treating a baby. While the baby was unharmed and no concerns were raised by the parents, the media storm which followed was a salutary lesson to all on the need to be very clear in communications with patients and how inappropriate and unwise it is to post videos of patient treatment. A review was called by the Victorian Minister of Health and its results will be presented to Australian Governments health ministers at the next COAG meeting. A review panel of 13 members has been selected including three persons representing the chiropractic profession. Chiropractic Australia has been assured that we will be able to make direct input to the panel. We advised all our members about the Chiropractic Board of Australia Interim policy on spinal manipulation which forbids the use of spinal manipulation on infants under the age of two years until this matter is resolved. The review called for public submissions and we advised members about this and provided

a link to enable submissions to be made. We firmly believe that you and your patients have strong voices which should be heard on this matter to help bring a true indication of the value of chiropractic before the review panel. In summary we believe that chiropractors play a most important role in the community in the care of people of all ages. Chiropractors modify their treatments on each and every patient to maximise safety and efficacy. While spinal manipulation is the most commonly applied treatment on older patients, clearly that is not the case on infants and babies; chiropractors also have expertise across a range of non-manipulative procedures such as soft tissue work, mobilisation and parent counseling to name a few.

Choosing Wisely We are continuing our formal involvement with Choosing Wisely, the international movement which opposes the excessive use of a range of unnecessary medical and other health care procedures. Board members Drs Dale Comrie and John Kaloger attended the Choosing Wisely National Conference in Melbourne in May. Our involvement is focused on stamping out poor diagnostic and treatment procedures, after which the high quality chiropractic care that Chiropractic Australia advocates can be showcased as best practice in the care of spinal and other mechanically based problems. In doing so we reinforce to government, to the public and to other stakeholders in health care that chiropractic is a responsible profession more interested in being a valuable member of the health care team, rather than a clinical

group that simply defends old-time practices which are out of step with reasonable evidence.

ANZMUSC Conference Chiropractic Australia is a proud sponsor of the Australia New Zealand Musculoskeletal Clinical Trials Network (ANZMUSC). Along with Board member Dr Michael Swain, I attended the Annual ANZMUSC Conference held at Royal Prince Alfred Hospital in Sydney on May 28/29th. In the room were several world leaders in clinically relevant musculoskeletal research and I am very proud to say that seven of the 70 attendees were chiropractors, almost all of whom were, or are, recipients of CA/ COCA funding. Proof positive that our commitment to supporting chiropractors in clinically meaningful research has and is paying great dividends. A number of times the expert speakers referenced the fine work that our chiropractors had published, showing it as being fundamental to them in their current investigations.

Rod Bonello BSc(Syd), DO, DC(SCC), MHA(UNSW), FRCC President

CHIROPRACTIC AUSTRALIA OFFICE Suite 2, 1 Rooks Rd, Nunawading Vic 3131 Ph: 1300 767 348 Fax: 1300 886 690

Email: : info@chiropracticaustralia.org.au www.chiropracticaustralia.org.au

CORRESPONDENCE AND ARTICLES stephen.kynoch@chiropracticaustralia.org.au

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Classifieds: Min charge: Members $40.00 - Non Members $78.00 Contact: Steve Kynoch Ph: 1300 767 348 or Email: info@chiropracticaustralia.org.au CA News is the newsletter of Chiropractic Australia and is published quarterly. CA News is fully protected by copyright and no part of this publication may be reproduced or transmitted in any form without the written permission of Chiropractic Australia , except as permitted under the Copyright Act. Advertising material is subject to review before acceptance. Chiropractic Australia reserves the right to accept or reject advertising at its discretion and without explanation. Advertising material contained within CA News in not necessarily endorsed by Chiropractic Australia. Readers should exercise their own judgement about whether the advertised service or product is likely to be of benefits prior to purchase. All requests for information regarding CA News should be made via Steve Kynoch. Chiropractic Australia, nor any of its servants or agents, will have any liability in any way arising from advice or information that is contained in CA News. The statements and opinions that are expressed in CA News reflect the views of the authors and do not necessarily represent the policy of CA unless otherwise stated, All rights reserved.

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INTERVIEWS

Interview with Dr Bobby Maybee By: Amber Beynon BSc (Hons), BChiro

Dr Bobby Maybee DC attended Western States Chiropractic College in Portland, Oregon and graduated in 2004. Since then he has been working as a chiropractor in private practice within the Portland area. He is also the president of Forward Thinking Chiropractic Alliance (FTCA). Dr Maybee will be a special guest speaker at this year’s Chiropractic Australia National Conference and he was kind enough to take some time to answer a few questions so we can get to know him before the conference. Q. What are the professional achievements you are most proud of? Honestly the moments I am most proud of when it comes to this profession are the clinical ones. The patient care ones. There have been times where I’ve used what I’ve learned in my education, in combination with my own personal skills and intuition, and something remarkable has happened. The moments where I’ve found a condition or disease that no one else has, an undiagnosed cancer for example, and then I was able to get the person the help they needed. Or encountering someone hurting inside and through compassion and communication, I’ve been able to show them a way to a new lease on life. The elderly lady who has resigned herself to a wheelchair, to see her speed walking again: not because of a magical adjustment, but through education, encouragement, and care. Those are the moments no one could ever take away from me and make the decision to be a chiropractor a gratifying decision. I am also very proud of our first Forward Convention that took place in 2018. It was such a deep pleasure to put on an event for evidence-based chiros and to see so many having a great time together in fellowship and learning. We are going to have more of those events, but that first one was very, very special. Q. Can you please tell us a bit about FTCA? The Forward Thinking Chiropractic Alliance began as a place on social media for evidence informed chiros to communicate about what we experience in our practices. I don’t know how it is in Australia, but in the USA 5 years ago or so when FTCA started, you couldn’t have a straightforward conversation about things like rehab, or research/evidence, or anything that didn’t fit straight chiropractic without a straight chiropractor carpet bombing your conversation with denigrations or insults. There were few, if any, places

people in the group do not realize their family is so large, they feel alone until they get in the group. One example is as simple as a book, like Don Murphy’s Clinical Reasoning in Spine Pain. Such a wonderful set of texts. I think it is an essential read for a chiropractor and even a physiotherapist. However, most people, MOST don’t even know about it. I’ve spoken at chiropractic colleges where the students are completely unaware of it. Through our group many people know it exists. And that’s just one example. We do that for texts, speakers, seminars, products, etc. If anything, I’ve become an influencer of sorts. A guide. And that’s what I’d like the FTCA to represent. The FTCA also has a paid membership function. The fees help fund the whole operation of web presence, podcast, seminars, content production and hosting, and any other projects we could hope to undertake in the future. I had found in the beginning many members wanted many thing and those things cost money and time, but very few were willing to contribute that money or time. Thankfully, like many other endeavours in our profession, there are about 10% of people who believe in FTCA enough to help fund what it does for the other 90%.

to go for such conversations. Not to mention skeptics from other fields.

Q. What do you see as the benefits of using social media within the

So I created a private Facebook group for people interested in moving the

profession?

profession forward in a progressive manner. We have done our best to be

The benefits of social media in the profession... well particularly for you Aussies this is a touchy subject at the moment. But I can put it this way:

selective in who has access to the group. And we’ve learned a lot from that over time. I have learned a lot about the realities of this profession, who we

communicate, and then like an on-ramp, direct/educate chiros and students

Take all of your various forms of advertising/marketing that have existed over the years. Print, radio, TV, yellow pages, and on and on and on, now to internet/social media. In each one of those forms of media, chiropractors have found a way to exploit or misuse the media in pursuit of patients. Are they the only ones? Of course not. But that’s not the point of this conversation although it still doesn’t excuse us of our behaviours. But through every medium, abuse has been found, and then the medium has

about all of the great resources available around the world. I think a lot of

had to be regulated. Social media has been the “wild west” for some time

are as a people generally, from running such a large group. I could go on forever about what the FTCA is or isn’t. It is not an organization such as Chiropractic Australia, or the American Chiropractic Association. And it will never replace them or any others. What I hope it becomes is a place where progressive chiropractors and students can

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INTERVIEWS

now. That’s an American term but I hope it translates. So it has huge potential

Ethical and effective marketing? I might have to share some DONTs, along

to be abused. And a lot of times I don’t think it is even abused intentionally.

with my DOs. But there are absolutely ways to let people know what you

I think there are many chiropractors that are not savvy to what they look like

do and where you are, without the social media and regulatory torch and

to the rest of the non-chiropractic world. To us, “cracking someone’s neck”

pitchfork folks shutting down your way of life. People with great power

is a daily occurrence, but to a vast overwhelming majority of planet earth,

need to know that includes great responsibility that shall not be abused

it is foreign.

without tremendous potential consequence.

So what we have is some docs, doing some things they THINK are

I am also sitting on a research panel. Little ole me. Never published once, not even in a comic book. But I’m there to represent the clinician, and speak to what we want from our researchers.

a good idea to put out into the world. And the unintended backlash ensues. In short, quite often social media can make monsters out of men. Chiropractic practice, for the majority, is “eat what you kill” private practice. Chiropractors have always clamoured for attention and recognition, sometimes to a fault. All mediums play into this, but social media takes that and multiplies it by a million. None of us are media marketing experts. As in, a TV ad executive that understands what sights, colours, and sounds people want to hear. Or words to avoid, etc. There’s a lot of chance for error. And since many of us work alone and fly by the seats of our pants sometimes, it can get you into trouble. I suppose I didn’t address the benefits. The benefits are that you can let people know where you are, and who you are, and what you stand for. You can do a much better job of attracting an ideal client. Social media is about community. Once people abandon it as solely a marketing vehicle to run targeted ads, and learn to build communities of value, they will be better off in practice and in life. And that was just marketing in regard to social media. Even as a social media “influencer”, I’m pretty down on the tool at the moment. When it comes to chiropractic, which already has a reputation of apathetic professionals, social media can make them even more apathetic. Docs can make posts and comments, so they feel like they’re doing something, but in reality all of the action takes place away from the screen. At events like CA and doing the work in person. Social media can make connections, but you still have to secure the connection in real life. One of the problems with social media for professionals is the blurred lines between being a professional, a business, and an individual with individual opinions. Dubious professional commentary can be passed off as “opinion” by a doctor. It’s hard for the public to know those differences and some people use that to their advantage. Q. What can we expect from you at the Chiropractic Australia

Q. Who are some inspiring people that you admire? Well, even though I am fully committed to this profession, I live a very full life outside of it. And I draw a lot of inspiration from outside of it as well. I’m inspired by people like Joseph Keating PhD, who was willing to ask questions about our profession people were unwilling to ask. I’m inspired by writers, and literally too many of them to name. Admiration is a very specific word choice. And I’d really have to think about “admiration”, I don’t think I hold many people in admiration at all, besides my wife and children. I do believe inspiration, motivation, even admiration can be gained from anyone and everyone when the moment arrives if you are open to it. Everyone has something they can give to you to make you better. Your supporters, your critics, the ones you’ve helped and the ones you’ve wronged. Happy patients and unhappy ones. Anyone. If you’re open. At this phase in my life I try to go one encounter at a time, and then ask myself after (and sometimes during if I’m lucky), “what does this encounter mean?” “What is the plot here?” That approach has probably led to some of the reasons why I’m an interesting “social media influencer”. There’s actually more mental steps to posting something online compared to saying something out loud and offhand. You have to think about it, type it, consider it (or not), and then push a button to send it. That means there’s a motive to the content sent. I always question the motive of the content. If you can do that, someone’s ideology or content can’t own you. You own them in a way. An ad will be an ad. An ideologue will be an ideologue. An internet “troll” will just be a troll. And the genuine folks will shine through. It’s a little secret sauce that made the FTCA so special. Years of trimming away inauthentic dead branches, like a bonsai tree, has left a large collection of really, really, good people. Not just chiros, but people.

conference?

Q. Do you have any hobbies?

I don’t know (ha ha).

Yes, I have hobbies for sure. I am a big basketball fan and played competitively for years “in my youth”. I could probably still play to a decent level, but something will snap in the process of proving it.

I always have an idea of what I’m going to give to attendees. But what I’ve found with conferences is that people will attempt to “censor” your input for the sake of appealing to an imaginary moderate middle of the profession. I’ve tried to respect that over and over, but it never works. It’s not authentic. Primarily because there is no “middle” in this profession. There are just a lot of different people who believe in a lot of different things and approaches and use chiropractic as the vehicle to accomplish them. So for one, I am going to be me. Don’t worry, “me” is nice and respectful and entertaining. But “me” is also unafraid to make statements that need to be said. I am going to be talking about non-confrontational things, so it should be a safe event. Gamification of rehabilitation is going to be exciting. How can we use technology and FUN to get patient compliance and results? That’s a home run presentation.

Here in the Pacific Northwest of America we get some rather large and prized fish species that migrate into our river systems. Salmon, Steelhead, Shad, Trout. I love fishing for them. I say fishing, not catching. Which is a metaphor for life. It’s about the act, not the result. My first year fishing was one of frustration, as I caught nothing. After catching a few big fish, the catching doesn’t mean nearly as much as it does to just be out there... fishing. You never know how an audience responds to hunting, but I am a very, very, avid bird hunter. It is my main obsession with my best friend, my Labrador Retriever, Jett. I do it for him and for dinner. Sometimes you do things with the people you love, because they love to do it. And that dog loves to hunt. Both the fishing and the hunting have been huge teachers in life. They are hobbies of competency. There’s something about having to

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INTERVIEWS master multiple subjects (navigation, concealment, dog training, fire arms ballistics and most importantly, safety), and then crawl around in the mud in the dark, and test hypothesis and ideas, listen to nature and what it tells you, all in hope of the reward of the hunt. And then to bring that reward home, to your family, properly care for it and prepare it, and present it to your loved ones. There’s a lot to that. A lot to absorb. But once again, you can be taught a lot when you are listening. And when you’re freezing your face off in the winter hiding in a corn field, there’s a lot of time to think. So the outdoors is a big friend of mine. Finally, with boys in the house, there’s some video gaming going on. Because sometimes you need to not think. And I read more books than Amazon could provide me. Q. What are your favourite films? Fight Club. Chuck Palahniuk, the author of the book, lives here in Portland.

Some have equated the FTCA to Project Mayhem, and I to Tyler Durden. Not far from the truth. The Matrix. All those earlier Will Ferrel movies that were funny. Documentaries. Historical Documentaries. Q. Is there anything else you would like to add? I look forward to visiting the Gold Coast, and your country in general. I don’t have a register for what a Chiropractic Australia event is like, I’m just going to show up and be myself. And you should too. There’s a certain wave that is made with each of these events. If an event speaks to you, you need to be there because it gives the ideas power, energy. More people show, better speakers show, sponsors show. And then it becomes a thing. You can’t complain about how your “thing” doesn’t have momentum in the world, if you aren’t there, somewhere, making it happen.

Interview with Dr Michael Swain on completing his PhD By: Amber Beynon B.Sc. (Hons), B.Chiro Michael Swain is a chiropractor, heath researcher and full-time lecturer at Macquarie University. He has successfully completed his PhD. A fantastic achievement! His research focused on adolescent musculoskeletal pain. He has also recently gained a promotion as a Senior Lecturer at Macquarie University. Mike was one of the original Fellows of the Chiropractic Academy for Research Leadership (CARL). He was kind enough to find time in his busy schedule to answer a few questions about his PhD journey. Q. Congratulations on successfully gaining your PhD! Can you tell us a bit about your PhD research? Thank you. My thesis investigated the prevalence, impact, risk factors, clinical course and diagnosis of common MSK disorders in adolescents. It included five publications: (1) a large study that estimated the prevalence of pain in adolescents from 28 countries across Europe and North America, (2) a study that estimated the association between pain and physical activity in adolescents, (3) a systematic review on the relationship between growth, maturation and musculoskeletal disorders in adolescents, (4) a longitudinal study on the short-term clinical course of knee pain in children/adolescents, and (5) a systematic review on accuracy of clinical tests for the diagnosis of anterior cruciate ligament injuries, which occur most commonly in adolescents/young adults. Q. The PhD journey is not an easy one. How did you find the experience? It was a busy, challenging, eye-opening and very fulfilling phase of life. I did my PhD part-time while working in a full-time academic (lecturer) appointment and seeing patients in clinical practice part-time. There were new challenges in all my roles that created a rich environment to learn and develop. PhD studies provided me with the opportunity to travel and to contribute to both chiropractic and multidisciplinary conferences. I have met and worked with talented and inspiring colleagues from all around the world, and meaningfully contributed to professional initiatives.

Back Pain Forum and Denmark in 2012. It changed my then insulated understanding of spinal pain, research/academia and the chiropractic profession. I became aware of new frontiers in spinal pain management/ research and how the “best-of-the-best” from various professions were tackling the spinal pain problem. I also became aware of the depth of outstanding academic leadership that exists in the chiropractic profession in Denmark, and particularly the culture and processes that are necessary to cultivate this level of achievement. In hindsight this experience was by design, my PhD supervisors empowered and encouraged me to travel abroad to experience the Forum. It was a “blinkers-off” moment for me, which came early in my PhD training.

Q. What would you say would be the highlight of your PhD journey?

Q. I know your research was around adolescent musculoskeletal pain, why do you think it is important to conduct research within this population?

There have been many successes, but my highlight is the experience that had the most profound impact on me, which was my first trip to the Low

Adolescence is a very important phase of life. Health and health behaviours during adolescence strongly predict health and health

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INTERVIEWS behaviours in adulthood. This is true for musculoskeletal conditions such as back pain. Adolescence is a vulnerable transition period in life. Several health conditions emerge for the first-time during adolescence. To become successful adults in our increasingly complex (socio-economic) world, children must traverse the precarious path of adolescent physical, emotion and social development. Resilience to various health conditions is acquired during adolescence, but so too is susceptibility. There is opportunity to have positive impact on the health and wellbeing of future

just amazing! I have had the privilege of working closely with Hazel Jenkins and Katie de Luca who are very talented and inspiring. Q. Do you have any hobbies? I love to surf and be active. When I get the chance, you’ll find me in the ocean riding waves. It has been difficult to get wet lately despite living close to the beach. I’m hoping that there will be some time to catch a few waves at the upcoming CA National Conference on the Gold Coast.

adults (where most of the MSK burden exists) by focusing our research

Q. What are your favourite films?

efforts on adolescents.

I like a variety of films. But I must say the Marvel movies are great for me as they tick the creative, adventurous, brave, and funny boxes all at the same time.

Q. What has been your experience as a CARL fellow? It has been an amazing experience. It is wonderful to be a part of a tight group of colleagues and friends who have all been through or are currently

Q. Do you have any advice for early career researchers?

going through the challenges of early career research. We support each

I’ll pitch my advice at potential Higher-Degree Research students. Carefully consider your motivations for doing a PhD before embarking. If you’re interested in acquiring a skill-set that will enable you to lead future research projects to advance the health of society then enrol in a top PhD program in clinical epidemiology. Seek out the best research group with the best culture and immerse yourself in it. Often the top groups will be supportive, competitive and project a strong sense of social justice. If you’re motivation for doing a PhD is socio-economic capital, do something else.

other, we discuss knowledge gaps and new ideas, and project work that is needed to progress our various fields of research. We inspire each other and demonstrate what is possible. For example, Andreas Eklund recently received our profession’s highest research award at the WFC congress in Berlin. Time with all the CARL Fellows and Mentors is special, and I feel very fortunate to have been appointed in this role. Q. Who are some inspiring people that you admire? My PhD supervisors Chris Maher and Steve Kamper are the most

Q. Is there anything else you would like to add?

inspiring, insightful and accomplished scholars I have had the privilege

It is great to be a part of the next generation of chiropractic academics, who have gone and acquired PhDs from outside of the chiropractic profession. In Australia, there is now a critical mass of early career researchers that can meaningfully develop the academic base of the chiropractic profession. What I believe is now needed is a consolidated effort and funding model from the profession to support scholarship moving forward. There are examples of successful models in Denmark (The Nordic Institute for Chiropractic and Clinical Biomechanics) and Canada (Canadian Chiropractic Research Foundation). Without such a model the profession’s progress is likely to resemble that of the past 20-years.

to know and work with. I have learnt so much from these two about research, scholarship, academia, mentorship and leadership. The Institute for Musculoskeletal Health is an amazing group that has a wonderfully balanced culture that is led by Chris and Steve, and the other senior academics there. I am also inspired by and admire my close colleag ue Aron Downie who manages to carry one of the most intense academic workloads imaginable while publishing big papers in big journals like the BMJ, Pain, and BJSM. Finally, our profession has some amazing superwomen who can juggle academic roles, PhD studies, clinical practices, give birth and raise children and families all at the same time.… they are

Interview with Dr Julie Kendall on completing her PhD By: Amber Beynon B.Sc. (Hons), B.Chiro Julie Kendall is a chiropractor, researcher and lecturer at RMIT University. She has successfully completed her PhD titled: “Falls risk in older adults: the impact of neck pain, dizziness and manual therapy treatment”. Congratulations! An amazing achievement! Her research focused on examining the association between neck pain, dizziness and balance in the elderly. She has also recently welcomed her daughter, Catalina, into the world. She was kind enough with her busy schedule to answer a few questions about her PhD journey for our membership. Q. Congratulations on successfully gaining your PhD! Can you tell us a bit about your PhD research? My thesis explored the risks of falling in older adults with neck pain and/or dizziness and the potential improvements in concerns of falling and balance through manual therapy treatment of the cervical spine. I found that neck pain was associated with increased concerns of falling and decreased physical performance in older adults; however, these relationships were complicated by many other factors. The factors W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U

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INTERVIEWS include mood, physical performance and previous history of falling. Also, intense neck pain, but not mild neck pain, is associated with reduced balance in mobility-limited older adults. I conducted a systematic review of non-pharmacological interventions for treating dizziness in older people, which found there was a lack of research in this area. Interventions that aim to reduce intensity of musculoskeletal pain need to be studied in older adults. Finally, it is feasible to run a large sham-controlled trial to examine the effectiveness of spinal manipulative therapy for neck pain and non-specific dizziness in older people, with modifications to increase recruitment. These trials should target older adults with bothersome or intense neck pain, to determine if alleviating these factors reduces the associated instability and falls risk. My thesis can be accessed here: https://researchbank.rmit.edu.au/view/ rmit:162634 Q. Can you tell us about some of the ups and downs you

wellbeing of older adults. However, I’m also interested in education, mental health, sleep and biomechanics. I’m excited to find out what opportunities I can make happen now that my PhD is finished. Q. How are you finding balancing being a lecturer, completing your research and also having a life? Hahahahaha! The big life question. Prioritising is important. I took much longer to complete my PhD than I anticipated because I was unwell, but as they say slow and steady wins the race. I find it useful to block out my calendar with activities, such as exercise, study and breaks. Also lists, lots of lists! Delegating and saying ‘no’ are underrated skills. Q. Who are some inspiring people that you admire? I admire the chiropractors who have helped pave the way for younger people like me to join them in research. Especially my supervisors Jan Hartvigsen and Simon French. It is not easy to make the transition from

experienced during your PhD journey?

clinical thinking into research thinking. I especially admire the women who

The intellectual challenge was the biggest highlight, increasing my critical thinking skills has carried over into all aspects of my life. I was also fortunate

amongst many others: Katie De Luca, Anne Mølgaard Nielsen, Eleanor

enough to be sponsored to visit the University of Southern Denmark where I worked with some of the leading chiropractic researchers in the world. It

work in academia as it can be tough so I would include these women Boyle, Charlotte Leboeuf-Yde, Alice Kongsted, Lise Hestbaek, Roni Evans, and Barbara Polus.

was an intimating and rewarding experience. Denmark is a wonderful place

Q. Do you have any hobbies?

to live and work. The research coming out is changing and improving our

I am part of a young adult book club. I also enjoy listening to podcasts,

profession.

watching television, and browsing online shoe stores.

Every PhD has its challenges. My biggest was maintaining my mental

Q. What are your favourite films?

health. I have a history of depression and anxiety, and I had a breakdown completing my thesis. It was really tough, but with support from my doctor, psychologist, partner, friends and colleagues I made it through. I owe so much to every person who encouraged me to keep going. Q. Where do you see your research going now? The best and worst part about being a chiropractic researcher is there is

I am more into television these days than films, especially with a little baby. At the moment I am watching Killing Eve, Game of Thrones, Queer Eye, Grace and Frankie, She-Ra, and Our Planet. Q. Do you have any advice for early career researchers? Just keep going. It is a marathon not a sprint. Ask for help and take it when it is offered.

so much research left to do! We can tap into so many areas of interest.

Q. Is there anything else you would like to add?

I want to continue to study ways to improve the musculoskeletal health and

Support chiropractic research!!!

Interview with Dr Katie Pohlman By: Amber Beynon B.Sc. (Hons), B.Chiro Dr Katie Pohlman, DC, MS, PhD is Director of Research at Parker University

My PhD thesis was titled: ‘Improving the Assessment of Safety in Paediatric

and an inaugural fellow of the Chiropractic Academy of Research and

Chiropractic Manual Therapy’, which was a project within a Canadian

Leadership (CARL) program. She has recently successfully completed her

Institute of Health Research (CIHR) team grant called SafetyNET. This team

PhD so congratulations are in order. Her research focused on the safety

of multi-disciplinary, international spinal manipulation experts had a goal

and effectiveness of chiropractic care in populations including individuals

‘to support a patient safety culture among spinal manipulation therapy

suffering from chronic pain, children, and pregnant/post-partum women.

providers’. Within SafetyNET, we developed a survey to measure patient

In addition to her degrees, she also has held certifications in chiropractic

safety attitudes and opinions among providers, which outcomes from

paediatrics and as a clinical research associate. She was kind enough with

chiropractors within paediatric organization made up my first thesis project.

her busy schedule to answer a few questions for our membership.

My second project was a comparison of SafetyNET’s active surveillance

Q. Congratulations on successfully gaining your PhD! Can you tell us a bit about your PhD research? I learned about the passion that many chiropractors have to care for the paediatric population at the same time that I discovered the gap in the literature for this care. This simultaneous discovery felt like an opportunity

methodology to collect adverse event reports to the more common way to collect adverse event reports, a passive surveillance methodology. Q. A hot topic right now is around paediatrics’ and manual therapy. One of your recent publications was very timely; Manual Therapy for the Paediatric Population: a Systematic Review. What

to help open doors for more children to get safe and effective patient care,

do you believe are some of the implications of this research?

whether this was with or without chiropractic care. I also knew that the lack of

This “state of the literature” was intended to help clinicians get a real

safety literature should be the first component explored intensively as I saw

perspective of where we are with evidence in this area. Unfortunately,

this to be the most concerning to parents and other healthcare providers.

as shown in this manuscript, we don’t have a lot of solid evidence--yet.

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CA NEWS JUNE 2019


INTERVIEWS However, over the past several years, the quality of the literature has been

potential international collaborators, and from the opportunity to practice

enhanced, as has the research in the area of musculoskeletal conditions.

presentations and review manuscripts/grants.

A lot of the manual therapy literature that was included in the review had

Additionally, many of us work in silos within our work environments and are

come from the osteopathic professionals who were self-funding the research projects. I believe this is another important take-home message from the paper: if we want more understanding/evidence on this topic, we (the chiropractic profession) need to step up and start to fund these projects.

at similar stages within our personal lives. I have handled many academic and personal scenarios with far more skill than I might have been able to otherwise thanks to having this trusted network of colleagues who are literally available 24-7, since the array of time zones means one of us is

Q. What role do you think chiropractors can have in paediatric

always awake.

populations?

Q. Who are some inspiring people that you admire?

Similar to the adult population, I believe we have a much larger role to play in

I have been so, so fortunate to be surrounded by constant inspirational

musculoskeletal conditions. The scientific community has recently raised the awareness of the negative impact that musculoskeletal conditions have on our society. For children, this awareness is still growing, but we do know that children with low back pain are more likely to be adults with low back pain. We also know that children with musculoskeletal pain are less active, which can impact their overall health. I believe that chiropractors can be part of a child’s healthcare team to manage these conditions, which could impact

individuals throughout my career. A woman who I have great admiration for has been a part of my scientific career since the beginning - Dr Cynthia Long. I often call her my scientific mom, as it was her generosity to give me the opportunities to discover my natural research skill sets and burning curiosity that set my career in motion. Dr Long is the Dean of Research at Palmer College of Chiropractic with a

their overall health and livelihoods.

PhD in biostatistics. I started my scientific career as a M.S. student in the

Q. Where do you think research with this population should go?

National Institutes of Health. In this program, her consistent professionalism

program that she developed and directed, which was funded from the US

‘Big data’ may seem like a buzz word in the current research, but it’s exactly

and mentorship focused on respect and high-quality methodology. From the

where we need to go. What I discovered in my literature review is that we

start of my career, when I was pretty sure I knew nothing, she made sure that

have inconsistent use of outcome measures and follow-up time periods.

I felt like I belonged, that I knew I deserved to be in the room. For any team

We need to first start with the determination of these items, then collect

that she led, it didn’t matter what position you had--everyone was equal and

this information from both within and outside the chiropractic profession.

their opinion mattered.

Clinical trials are ideal; however, they are expensive. In addition, recruitment is difficult, as parents who want chiropractic care for their child can obtain it outside of a clinical trial. Collecting high-quality ‘big data’ will allow us to

She continues to be a hidden gem. Her impact has and will continue to advance our research; she’s an asset to the profession.

better understand the care that we are providing, as well as the outcomes

Q. Do you have any advice for early career researchers?

we are getting. Out of that understanding, clinical trials can be designed with

Stay open to opportunities, even when they appear trivial. It is by being

more rigor and higher impact.

willing to get in the dirt that you will discover how much you love (or hate)

Q. What are you currently doing? As the Director of Research for Parker University, a major portion of my

research. Walk through open doors—it’s often the ones that you aren’t sure about that offer incredible value down the road.

time is spent supporting the research of others. That usually looks like the

Q. If there anything else you would like to add?

enhancement of evidence-based and research activities for the faculty,

Thanks again for this opportunity. Having the opportunity to share my

students, and professional staff. These activities have truly taken off with

research activities is always a pleasure. I am inspired by all of the research

lots of energy and momentum for more knowledge in this area, which has

advancements our profession has made, and I’m looking forward to where

been inspiring to see. As we all know, research isn’t done by lone wolves,

we are going.

so I have been developing professional collaborations with both local and

1. Pohlman KA, Carroll L, Hartling L, Tsuyuki R, Vohra S. Attitudes and

international organizations that will help the University to continue to grow their research capacity. My own scientific projects continue to evolve. For the paediatric population, I continue to write manuscripts from data collected within my PhD thesis, as well as the development of further research from what was learned/ discovered from that data. For the pregnancy/post-partum population, I am a part of a team performing a systematic review and creating a best-practice guideline document. Additionally, together with my colleague at Canadian Memorial Chiropractic College, Dr Martha Funabashi, I’m continuing with SafetyNET and other patient safety research projects.

opinions of doctors of chiropractic specializing in paediatric care toward patient safety: a cross-sectional survey. J Manipulative Physiol Ther 2016 Sept;39(7):487-493. 2. Pohlman KA, O’Beirne M, Thiel H, Cassidy JD, Mior S, Hurwitz EL, Westaway M, Ishaque S, Yager JY, Vohra S. Development and validation of providers’ and patients’ measurement instruments to evaluate adverse events after spinal manipulation therapy. Eur J Integrative Medicine: special Patient Safety edition 2014;6(4):451-466. 3. Pohlman KA, Carroll L, Tsuyuki RT, Hartling L, Vohra S. Active versus passive adverse event reporting after paediatric chiropractic manual

Q. What has been your experience as a CARL fellow?

therapy: study protocol for a cluster randomized controlled trial. Trials

CARL has been a game-changer for me, both professionally and personally.

2017 Dec 1;18(1):575.

The program fast-tracked the opportunity to know and learn from the best in our field. I do believe all of us [the CARL fellows] would have known each other and likely worked together at some point in our careers, but this program provided the opportunity much sooner. The CARL fellows and mentors combined have a vast wealth of research expertise and topic of interests, which have allowed each of us to become more knowledgeable in so many areas. This knowledge comes from collaborative research opportunities, from introductions to W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U

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NEWS

Chiropractic History: The Lerner Report By: Dr Kenneth Young DC, DACBR, MAppSc (Medical Imaging)

There is a problem with research. Actually, maybe I should put it this way: There’s a problem with Research. The capital letter indicates reference to the entire notion of research as we currently practice it globally. The problem with Research is that humans are doing it. I realize that you must think that I have lost a couple of apples off my tree, but here is what I am getting at: Human flaws and interests are reflected in the research that we do. Bias is rife, and not just the usual biases that spring to mind, like confirmation bias or choosing a statistical method that best achieves the results we wanted. Bias is demonstrated in

what that was or if it still exists, but it sounds

copy and disseminated it to interested parties.

impressive, doesn’t it? Another client was

Keating gave me one while I was a student at

Joseph P. Kennedy, patriarch of The Kennedys,

Los Angeles College of Chiropractic.

you know, presidents, senators, attorneys general, etc. Sometime around 1950, the Foundation for Health Research, Inc. (FHR), a not-for-profit chiropractic entity, hired him to investigate the profession. Chiropractic was often portrayed by organized medicine (the American Medical Association (AMA), and other groups), and in popular media as having no scientific basis and as being a danger to public health. The idea behind the FHR commission was to get a neutral party to explore chiropractic theories, practice, and techniques, in order to counter negative chiropractic propaganda.

Lerner approached his work in the way that might be expected from his training as a lawyer. He compared the problem to one of making an appeal to overturn a previous court decision: “Let us compare the problem to the task facing a litigant in a court proceeding. A verdict has already been rendered [unfavourable to chiropractic], and the litigant is seeking to win a new trial. How can he proceed? He must try to show the following: (a) That a ‘mistake’ has been made during the progress of the trial, adversely affecting the Court and the Jury in their deliberations, or (b) That ‘new evidence’ has been

choosing what to study, or what not to study,

The FHR was not affiliated with any professional

found, which was not presented at the trial, and

how to study it, and then whether or not to

organization and was funded entirely from

which is believed could have swung the verdict

publish the results depending on what the study

private contributions. Chiropractor Lyndon

the other way. A search began for ‘new evidence’

found. The issue is not confined to chiropractic

Lee was a senior consultant to the FHR, and

and any ‘mistakes’ that had been made.”

by any means, but chiropractic will be my focus

he stated the purpose of the investigation this

for this article.

way: “...our interest lies in establishing fact and

Negative studies, that is, studies that yield negative results, are not always published, but positive studies usually are.1,2,3,4,5 That is a problem. It is just as important to know what a particular treatment is not good for (a non-indication) as it is to know what it is good for. Recent research shows that chiropractic students are particularly bad at identifying nonindications for chiropractic treatment.6 Maybe if more studies with negative results were published, this would not be the case. Maybe professionwide, we are letting ourselves down by failing to discuss non-indications properly.

unearthing the truth concerning the chiropractic claim that vertebral subluxation, interfering with transmission of nerve energy, will cause disease. It is our purpose to test the chiropractic hypothesis with objective approach; to build a body of knowledge which will present scientific proof respecting this subluxation theory. Either chiropractic is founded upon a sound principle or it is not. Chiropractic deserves inclusion in the family of health professions on merit or it deserves to be revealed as not possessing value.” Lerner dutifully carried out his mission, taking two years for his study, and he submitted a manuscript 780 pages long to the FHR in 1952.

Lerner noted that chiropractic had been advancing the same arguments for 50 years. Why had new evidence never been presented during that time, in order to “win” the case with the public and courts? In studying the development of the profession, he struggled to find a coherent set of facts. “Nearly all of the writings examined on the ‘Story of Chiropractic’ gave the feeling of one wandering through a fog. A clear picture could not be obtained.” Having read quite a bit of DD’s and BJ’s writing, I find this find this blunt metaphor accurate, if unflattering. Lerner continued: “There seemed to be no continuity in the historical accounts published. There was something missing, stirring up curiosity to know what it was. The facts concerning the origin of

Here we run up against more human frailties. We

Lerner uncovered some findings regarding the

all want good news. We all want our profession

early history of chiropractic that had not been

to be found highly useful. We often have an

previously revealed. The report inspired the

emotional attachment to the way we practice.

FHR to submit a grant proposal to the National

We might even have a financial interest in seeing

Institutes of Health (NIH) for a controlled clinical

one or another technique system show positive

trial in 1959, a first for chiropractic. Although

results. But if we are to practice patient-centred

rejected by the NIH, the application itself was

care, not chiropractor-centred care, we must be

a milestone for the profession. Lerner was

aware of these issues and address them.

thorough and unflinching in his examination.

He began by noting the 19th century tendency to

Too thorough and unflinching for some. In

announce a discovery, then set it up as an “Art,

1965, Dave Palmer (grandson of DD, son of BJ)

Science, and Philosophy.” He then dismissed

rejected the findings in the Lerner Report, and

the art and particularly the philosophy: “The

it was never released to the public. Decades

attempt to create a philosophy of Chiropractic

later, long after most of its relevance had faded,

brought its proponents unwittingly into the realm

William Rehm and Joseph Keating found a

of speculation. They began reasoning and

Wait, I thought this was a history column. It is. So, to the historical part. It starts with Cyrus Lerner, a prominent attorney in the 1940s and 50s. His clients included the Hydroton Corporation of New York. I have no idea

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CA NEWS JUNE 2019

Chiropractic made one wonder what was ‘history’ and what was ‘twistory.’ Why hadn’t the full case been presented to the people? What was being withheld? If only the entire story could be told?” At this point, Lerner seems to wish for a positive outcome: “Could the people be ‘re-educated’ to Chiropractic?”


NEWS

rationalizing and offered opinions and views on

future of Chiropractic than the danger, which

profession and continue to keep our focus on

the subject of life, health and disease, which were

has been created by the wrangling of the

the profession rather than the patient. Cyrus

unacceptable; it produced every kind of ridicule

various personalities within the profession for

Lerner, 70 years ago, shone a light on a path

and provoked the non-believers to say that

control and supremacy. If the whole truth about

that we can still see, but have yet to take.

the ‘claims of Chiropractic’ were absurd; even

Chiropractic were known, the knowledge would

fraudulent.” He embraced a scientific approach

enable the leaders of the profession to better

that would seek new evidence for the phenomena

contemplate the future growth and development

produced by the chiropractic adjustment,

of Chiropractic.”

proposing several research projects.

Kenneth Young is the curator for the Chiropractic History Special Collection at Murdoch University. It can be seen here: https://www.murdoch. edu.au/library/resources-collections/special-

I will not summarize the entire report here; you

collections/chiropractic-history-collection,

Lerner advocated a transparency never before

can read it if you like at chiro.org. But for today’s

or search ‘special collections’ on the main

adopted by chiropractic. He found that DD and

column, this is the relevant part. This is the

university website, www.murdoch.edu.au. If you

BJ had changed their theories of chiropractic

history from which we, collectively, still have not

would like to comment on this article, or want

and adopted the nerve theory as a politically

learned. There are still too many unaddressed

further information on the Special Collection, or

expedient action rather than one with a true

issues in chiropractic, too many things we only

to discuss making a donation of money or items,

clinical basis, in order to “to make the ‘facts’ fit

whisper in “safe” groups. There are negative

please contact Ken at k.young@murdoch.edu.

the requirements of a new law on Chiropractic.”

findings we do not publish, studies we do not

au or on (08)93607370.

He noted that the full history of chiropractic,

undertake for fear of the results, evidence (or

even the uncomfortable parts, had to be

lack of it) we do not consider, because it might

faced in order to progress. “This withheld-

be painful to do so. But failing to consider these

information is, in our opinion, more vital to the

issues will only continue the stagnation of the

This article only reflects the personal views of the author and does not reflect the views of Murdoch University.

1. Mlinarić, A., Horvat, M., & Smolčić, V. Š. (2017). Dealing with the positive publication bias: Why you should really publish your negative results. Biochemia Medica, 27(3), 447-452. doi:10.11613/BM.2017.030201 2. Atkin, P. A. (2002). A paradigm shift in the medical literature. British Medical Journal,325(7378), 1450–1451. 3. Csada, R. D., James, P. C., & Espie, R. H. M. (1996). The “file drawer problem” of non-significant results: Does it apply to biological research? Oikos, 76(3), 591–593. 4. Fanelli, D. Negative results are disappearing from most disciplines and countries. Scientometrics (2012) 90: 891. https://doi-org.libproxy.murdoch. edu.au/10.1007/s11192-011-0494-7 5. Porter, R. J., Boden, J. M., Miskowiak, K., & Malhi, G. S. (2017). Failure to publish negative results: A systematic bias in psychiatric literature. Australian & New Zealand Journal of Psychiatry, 51(3), 212–214. https://doi.org/10.1177/0004867416683816 6. Innes SI, Leboeuf-Yde C, Walker BF. Chiropractic student choices in relation to indications, non-indications and contra-indications of continued care. Chiropr Man Therap. 2018;26:3.

In Memoriam: Dr John Sweaney AM

Chiropractic Australia is saddened to learn that Dr John Sweaney has recently passed away. Our sincerest sympathies are extended to his family and friends. Dr Sweaney contributed to the development of the chiropractic profession here

in Australia and around the world. His lifetime contribution to the profession has been truly

Chiropractic Advisor to the Department of Veterans Affairs (7 years). He was Vice Chairman

outstanding.

of Chiropractic Education Australia and served on various committees of the Chiropractic Board of Australia and the Chiropractic Council on Chiropractic Education Australia. Dr Sweaney received an honorary doctorate from Murdoch University (WA) and was awarded the Order of Australia in 2007 for services to chiropractic education.

Dr Sweaney graduated, with honours, from the Canadian Memorial Chiropractic College in 1968, served as the President of the Australian Chiropractors Association from 1979 to 1981 and as its Executive Director from 1985 to 1999. He was President of the World Federation of Chiropractic (WFC) for 3 years and served on its executive for 12 years. He drafted the WHO’s Guidelines on basic training and safety in chiropractic published in 2005. These guidelines have been translated into 11 languages and led to greater acceptance of chiropractic by governments in many countries. Dr Sweaney also served as a Deputy Director on the Federal Government’s Professional Services Review Tribunal (17 years) and was the National

Paying tribute to Dr Sweaney, Dr Wayne Minter said, “Dr John Sweaney always demonstrated impeccable integrity, great political judgment and was a wonderful colleague and friend.” He had a profound understanding of the issues facing the chiropractic profession. His contributions and service to the profession will be missed and not be forgotten.

W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U

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12

CA NEWS JUNE 2019


NEWS

The Chiropractic Australia Journal Club By: Andrew Shepherd BSC Chiro Sc, M Chiropractic

In this edition of the Journal Club we look at three papers: Establishing a residency program for a chiropractic specialty in a public hospital system: Experiences from Denmark (O’Neill et al, 2019); The shape of chiropractic in Europe: a cross sectional survey of chiropractor’s beliefs and practice (Gislason et al, 2019); and The paraspinal muscle-tendon system: its paradoxical anatomy (Creze et al, (2019). The paper by O’Neill et al (2019) discusses three pilot programmes undertaken in Denmark between 2009 and 2016 as a fiveyear post graduate chiropractic residency in a public hospital. The aim of this programme was to establish a new role for chiropractors in a hospital setting, positioning them as chiropractic specialists alongside established medical specialists such as radiologists, spinal surgeons, and rheumatologists. Chiropractic in Denmark enjoys a high degree of integration with mainstream medicine but nevertheless received some resistance from the medical profession which was somewhat negated by clear goals of the programme that were established in 2008 by a preliminary white paper. This paper outlined the roles of chiropractic specialists in this setting which included a high degree of clinical competence beyond the usual postgraduate competencies, the ability to work as part of a health-care team and the development of specialist skills in terms of diagnostics, imaging, and treatment. The programme was divided into three levels of competence. The first being the ability to work autonomously and be able to order imaging and other diagnostic tests without the need for referral first. The second was competence in the resident’s ability to perform some of the functions of other specialists and work collaboratively with them and the third, the ability to correctly

identify the need for referral directly to the appropriate medical specialists. These three competencies align with the concept of the chiropractor in a hospital setting as a musculoskeletal general practitioner. The residencies began in 2009 and ended in 2016. The pilot was a success and resulted in completion by 2 residents in 2016, a following 1 resident in 2017 and a further 2 in 2018 conferring specialist status on the residents and an ongoing programme at the Hospital of Lillebaelt as part of its professional development activities. Only a few chiropractic programmes around the world have established hospital residencies or internships but not to the degree as the Denmark model described in this paper. The leaders of the programme found that some challenges arose such as graduate commitment to a 5 year post grad residency, establishing good relations with the hospital and staff and working collaboratively with them to further develop the programme and defining the chiropractor’s role in a hospital setting, traditionally filled by medical specialists. It is likely that the establishment of cultural authority of the chiropractic profession in Denmark through a commitment to the evidence-based model of practice facilitated this programme. To be able to translate this to chiropractic programmes in other countries is also likely to be dependent on the cultural authority established in those countries, however, being able to do so opens up great opportunities for dedicated new graduates beyond private practice. Following on from this brings us to the next paper by Gislasson et al (2019) which is based on a survey of chiropractor’s beliefs and practices in Europe. Most people in the profession are aware of the rift between evidence-based and vitalistic chiropractors largely along ideological lines and the practices that go with them. Few studies have attempted to qualify the traits that separate the two groups or quantify the numbers within them. One such study was conducted in Canada recently but this is the first of its kind conducted in Europe. The survey centred around practice behaviour that was inconsistent with evidencebased guidelines and considered unorthodox. The orthodox group consisted of roughly eighty percent of those surveyed and twenty percent for the unorthodox group.

Unorthodox behaviours included percentage of new patients x-rayed on the initial consultation. Twenty three percent of the unorthodox group x-rayed greater than 50% of their new patients as opposed to five percent in the orthodox group. Twenty two percent had greater than 150 patient visits in one week in the unorthodox group compared to half that number in the orthodox and those who either disagreed or strongly disagreed with the statement “In general, vaccinations have had a positive effect on global public health” were 57% and 4% for the unorthodox and orthodox groups respectively. These results were very similar to those in the Canadian study. The conclusions of the European study were that unorthodox beliefs are predictive of unorthodox clinical behaviour. Such behaviour is considered inconsistent with public health guidelines and such a substantial percentage of practitioners still conducting this type of practice behaviour has potentially serious implications for the future of the profession in Europe and likely elsewhere. Considering the Denmark model and its high level of integration into mainstream medicine, good utilization rates and a largely evidencebased model of practice which has allowed the country to integrate the profession into a hospital setting it seems only logical that unorthodox practices should be eliminated in other countries if the profession is to move forward into the future. The final paper by Creze et al (2019) deals with a new anatomical perspective on the lumbar paraspinal muscles (LPM) and its implications for lower back pain and its management. This article describes the paradox between the large cross sectional area (mCSA) of the LPM, the relatively very small cross sectional area of its tendons (tCSA) and the LPM’s function. It is considered paradoxical because typically a muscle of large mCSA is able to exert a large force on its bony attachment and therefore needs a large tCSA in order for the tendon to transmit that force without damage. This study compared the tCSA to another muscle with the same relative tCSA but unable to produce much force as a result, the extensor digitorum communis (EDC). This muscle was chosen as it shares common features with the lumbar erector spinae except its muscle to tendon cross sectional ratio (rCSA) is relatively equal.

W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U

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NEWS The rCSA predicts the maximum force a muscle can transmit to the bone. So the EDC is capable of moving a single digit, but the large mCSA of erector spinae can produce similar forces to that of the quadricep muscles. How then does its tendons simply not tear when producing lumbar extension? The authors argue that rather than producing extension, the erector spinae produces stiffness in a rigid compartment parallel to

the lumbar spine to stabilize it while forces are transmitted through the relatively thin and small tendons to the fascial slings, mainly the thoracolumbar fascia which produces the actual extension.

This new information may shed light on the effects of treatment of the myofascial tissues in combination with spinal manipulation for the treatment of lower back pain.

Other research has demonstrated that a loss of mCSA in the LPM is associated with lower back pain, and rehabilitation exercises that increase it is associated with a decrease in lower back pain.

Chiropractic & Manual Therapies Journal Attains An Impact Factor By: Professor Bruce F. Walker AM, DC, MPH, DrPH, FRCC (UK) - Editor-in-Chief Chiropractic & Manual Therapies has been

the journal over its long 29 year history. While

least) the contribution of necessary resources by

notified by our publishers (BMC a division of

there are indeed too many to mention, it would

the four joint venture partners* who sponsor the

SpringerNATURE) that according to the Master

be remiss not to identify some very important

journal has provided the critical funding to allow

Journal List of Clarivate Analytics, Chiropractic &

contributors to this milestone accomplishment.

the journal to prosper.

Manual Therapies (CMT) has been included in

First, the staff of BMC whose professional

the Science Citation Index – Expanded (SCIE),

stewardship over 14 years has been outstanding.

under the ‘Rehabilitation’ category. Journals in

The CMT editorial team consisting of Simon

the SCIE are indexed in Web of Science, and also

French, Iben Axen, Peter McCarthy, Jeff Hebert,

receive an Impact Factor. Given that this decision

Stephen Perle and more latterly Alice Kongsted

was made very recently, CMT won’t get an Impact

whose pro bono efforts have been outstanding

Factor with this year’s release of the JCR (which

and pivotal. Charlotte Leboeuf-Yde’s continuous

* Chiropractic Australia, Nordic Institute of

will happen in the next few weeks). However, it will

belief in the journal and her wise counsel as

Chiropractic and Clinical Biomechanics, Royal

receive an Impact Factor in June 2020.

senior editorial advisor has been outstanding.

College of Chiropractors (UK) and the European

The editorial board has provided advocacy,

Academy of Chiropractic (ECU).

This achievement means that CMT will be the first journal in the world with “chiropractic” in its title about to attain an impact factor.

Thank you to all who believed in the journal and to the many readers who have accessed articles. The journal is now truly established and with your continued help will thrive in the coming years and decades.

reviews and advice regarding the journal that paved the way for success. Authors and peer reviewers are to be acknowledged as well as

The success is due to the collective efforts of

Murdoch University for supporting my time as

a large group of people who have supported

Editor-in-Chief over many years. Finally, (and not

C&MT Journal Article Summary The acute effects of joint manipulative techniques on markers of autonomic nervous system activity: A systematic review and metaanalysis of randomized shamcontrolled trials. https:// chiromt.biomedcentral.com/ articles/10.1186/s12998-0190235-1 14

CA NEWS JUNE 2019

Many chiropractors and osteopaths think that joint manipulative techniques, especially spinal manipulation, can influence the autonomic nervous system, but what does the literature reveal on this topic? We did a systematic review of studies comparing autonomic activation following a mobilization or a thrust manipulation to that of a sham procedure. The results showed that some types of mobilizations did increase skin sympathetic nerve activity regardless of the ‘treated’ area, as shown by an increase in skin conductance (i.e. sweating). This finding is interesting in an experimental context but

has limited clinical relevance. Our results also showed that a spinal (high velocity low amplitude) manipulation may have no acute effect on autonomic activity. There are still gaps in our understanding of this topic, so there will likely be more research needed to make these conclusions more certain. Regarding the current state of knowledge, our main message for chiropractors and other manual therapists is that the use of spinal (high velocity low amplitude) manipulation to obtain specific acute effects on the autonomic nervous system is not supported by scientific evidence.


NEWS

WHO focus on low back pain demonstrates unprecedented opportunities for chiropractors Toronto, June 5, 2019 The World Health Organization has published a paper in its Bulletin that warns of the risks of over-medicalizing the management of low back pain, instead advocating care that chiropractors are highly qualified to provide. The paper(1), authored by leading experts from Australia and the UK, proposes nondrug, non-surgical approaches as the first line treatments for low back pain. They include advice, education and reassurance with manual therapies including spinal manipulation for patients at risk of developing chronicity. The paper’s authors were particularly critical of the overuse of spinal surgery, hospitalization, injections, complex pharmaceuticals and diagnostic imaging. This mirrored the strong evidence cited in a series of articles on low back pain published last year in The Lancet. The WHO Bulletin paper found that despite international recommendations, it was conservatively estimated that 32% of care

provided for low back pain in the USA was inconsistent with clinical guidelines, including a rise of 62% in elective spinal fusion surgery (2004-2015) in the USA, despite no good evidence of benefit over non-surgical care. “As spine care specialists, chiropractors are perfectly positioned to provide evidencebased, people-centered care for low back pain,” said WFC President Dr Vivian Kil. “All of the top guidelines published in the past few years are telling us that non-surgical, nondrug care is the preferred approach. Spinal manipulation is increasingly being seen as the treatment of choice. Chiropractors are highly skilled in this technique but can also deliver many of the other recommended interventions, such as patient education, soft tissue techniques and self-management advice.” For chronic persistent low back pain, the

evidence-based care to underserved communities. We know that in low- and middle-income countries many people have no access to health care, let alone spine care. Chiropractors have all the skills to make a real difference to the lives of those suffering from spinal pain and disability.” The WHO Bulletin paper criticizes the persistent use of opiate painkillers for chronic back pain despite research showing limited benefit and the US Center for Disease Control being very clear that they should not be used for chronic, non-cancer pain. Yet many health systems remain non-compliant with guidelines at the expense of patient outcomes and huge costs. As spine care experts, chiropractors are well-placed to re-educate patients around the many myths and misconceptions surrounding back pain management. Dr Kil continues,

guidelines recommend a multidisciplinary approach. As part of its #BeEPIC campaign, the WFC recommends interprofessional and collaborative care and increasingly chiropractors are engaging positively with spine care professionals from other disciplines.

“Back pain is one of those conditions where everyone wants to give advice, but the reality is that it is not always grounded in evidence. Staying active and mobile may seem unnatural when you’re in pain, but it works and the guidelines support this approach.”

WFC Secretary-General Richard Brown commented: “As well as meeting demand in high-income countries, more chiropractors are needed around the world to deliver

1. Traeger AC, Buchbinder R, Eishaug AG, Croft PR, Maher CG. Bulletin of the World Health Organization 2019;97:423-433. doi: http:// dx.doi.org/10.2471/BLT.18.226050

Notes • The WFC is the only chiropractic organization to be a non-state actor in official relations with WHO. • It represents the national chiropractic organisations of over 90 countries in 7 global regions. Headquartered in Toronto, Canada, its current Interim President is Dr Vivian Kil of the Netherlands.

National Conference 2019 23 – 25 August Sofitel Broadbeach on the Gold Coast

“It’s going to be exciting!” W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U

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Hands on India 2020

You've heard about it, why not join us? Sat 1st - Sat 15th February 2020 (meeting in Delhi)

In just 2 weeks serve more, see more and learn more than in a lifetime in practice! Experienced chiropractors -

• • • • •

work as part of a team sharing your skills, knowledge and case management volunteer in communities that love receiving our care and see how you really make a difference see and be part of the ‘real India’ full of colour, excitement and wonderful people. help mentor our new grads and be part of the diverse chiropractic community gain CPD hours with seminars, extensive case and technique tutorials (hours pending)

New graduates-

• • • • •

jump start your professional life and get real ‘hands on’ experience, use your university knowledge - see the real neuro cases and more pathology than a life in practice extensive case, exam and technique tutorials be mentored by amazing chiropractors happy to share their knowledge and wealth of experience must be registered and have professional indemnity insurance by Jan 25th 2020

What to expect - we stay as guests of Seva Kendra mission in remote north east India. For 2 weeks we travel by day in jeeps to makeshift clinics in the hard manual labour regions of tea plantations and rock breaking community to serve the people with minimal access to health care. Hands on India teams of 30 provide care to approximately 4000 patients during our 2 week stay! During our trip you will spend time seeing results of positive changes in the Siliguri region community. Fund raising from previous trips has allowed us to fund education in 7 schools (700 children) and supports 2000 Women in Empowerment projects. Predicted cost:

• approximately $3000 (airfares, accommodation, meals, uniform and on ground costs) • minimum donation/fundraising of $1000 per attendee - towards the Seva Kendra community • additional expenses - personal travel (optional pre trip visit to Agra to see the Taj Mahal), spending money, visa, insurance etc

Spaces strictly limited, so register your interest ASAP by email for selection. Team Leader 2020: Sue Ferguson

hands_on_india@outlook.com www.handsonindia.org.au 16

CA NEWS JUNE 2019


NEWS

Update - Platelet Rich Plasma for Knee OA By: Dr Nicholas Shannon PGDipSEM, ICCSP

Platelet rich plasma (PRP) is an autologous derived blood product that contains high levels of growth factors which combat against chondrogenesis and aim to improve pain and function(1). It is a relatively new biological intervention that has gained popularity thanks to professional athletes like Kobe Bryant, Rafael Nadal and Tiger Woods. However, the research supporting the use of PRP has been lagging, and in many conditions where it is clinically used like achilles tendinopathies, hamstring tendinopathies and tears, and rotator cuff tears and tendinopathies, it is lacking and often of poor quality. In some cases, there is no evidence to support the use of PRP and in others, such as lateral epicondylar tendinopathies it may be useful when combined with other interventions, like eccentric loading exercises(2,3). However, there is a slow growing body of evidence to support the use of PRP in patients with mild knee osteoarthritis (OA). Two double blinded, randomized controlled trials in 2017 and 2019 have shown, that multiple injections of PRP (usually 3 injections over 3 weeks) for those with early OA show clinically significant improvements in knee pain and function outcomes (WOMAC and IKDC scores) when compared to hyaluronic acid (HA) injections and placebo (saline) over 12 months(4,5). With better outcomes seen in younger patients with milder OA. PRP has been shown to be safe with most side effects, such as swelling and pain self-limiting within a couple of days post injection(6).

Does this mean we should be rushing out and referring all our patients with OA knee pain for PRP injections? Definitely not, as further supporting evidence is required. Knee OA should be managed through a patient centred plan, which should include dietary and lifestyle advice, especially for those who are overweight. Exercise therapy, which is supported by high quality evidence for reducing knee pain and by moderate quality evidence for the improvement of knee function(7–9). At an interventional level, PRP should be discussed with patients alongside corticosteroid injections (CSI) for those not responding to more conservative management or who require some additional assistance to start their exercise therapy.

Treating knee pain due to OA is clinically challenging, however such patients will present to chiropractors. Chiropractors are well positioned to provide dietary and lifestyle advice, prescribe appropriate exercises and offer advice on alternative biological intervention options to traditional NSAID’s and corticosteroid injections which are often prescribed for pain associated with knee OA by primary care physicians(10).

REFERENCES: 1. Liou J-J, Rothrauff BB, Alexander PG, Tuan RS. Effect of Platelet-Rich Plasma on Chondrogenic Differentiation of Adipose- and Bone Marrow-Derived Mesenchymal Stem Cells. Tissue Eng Part A. 2018 Oct;24(19–20):1432–43. 2. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of Platelet-Rich Plasma for Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Randomized Controlled Trial of 230 Patients. Am J Sports Med. 2014 Feb 1;42(2):463–71. 3. Hussain N, Johal H, Bhandari M. An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature. SICOT-J. 2017 Oct 9;3:57. 4. Görmeli G, Görmeli CA, Ataoglu B, Çolak C, Aslantürk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2017 Mar;25(3):958–65. 5. Lin K-Y, Yang C-C, Hsu C-J, Yeh M-L, Renn J-H. Intra-articular Injection of Platelet-Rich Plasma Is Superior to Hyaluronic Acid or Saline Solution in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized, Double-Blind, Triple-Parallel, Placebo-Controlled Clinical Trial. Arthrosc J Arthrosc Relat Surg. 2019 Jan 1;35(1):106–17. 6. Dai W-L, Zhou A-G, Zhang H, Zhang J. Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2017 Mar;33(3):659-670.e1. 7. Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsøe B, Dagfinrud H, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016 Mar 23;3:CD005523. 8. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015 Jan 9;1:CD004376. 9. Hurley M, Dickson K, Hallett R, Grant R, Hauari H, Walsh N, et al. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane Database Syst Rev. 2018 17;4:CD010842. 10. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363–88.

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NEWS

Meet the new graduates Graduation ceremonies for the Class of 2018 from Macquarie University, Murdoch University, Central Queensland University and RMIT have been held in recent months. Chiropractic Australia was in attendance at each event to continue our support of chiropractic students and to present certificates and prizes to top students. Below is a selection of photos and comments from students from some of these events.

Murdoch University Graduating Class of 2018

My journey was a marathon, sprint, and mountain climb concurrently, however I found mentors who helped me develop into the qualified chiro I now am, hopefully it will be a wide flat road from here on out. Josh Steen - CQU Graduate CQU Graduates

My journey at CQU, as one of the inaugural class members at the Brisbane campus, over the past five years has been tumultuous to say the least. The journey itself has taught me to be both a stronger person and how to seek further education when required. The support I received from some graduated chiropractors over the five years has been amazing; rather than telling me what to think, they constantly questioned me, and I constantly re-evaluated my position, which is ongoing to this day. Overall, the experience has been great.” Nicky Urmston – CQU Graduate

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CA NEWS JUNE 2019


NEWS

Macquarie Graduation Ceremony

Macquarie Graduate Ingrid Dunkley

How did you find the experience of studying Chiropractic at Macquarie University?

What are your plans now? To really work on applying the skills I’ve learnt throughout my degree and build a Chiropractic Practice that I am proud of.

Studying chiropractic at Macquarie University was a challenging and fulfilling experience. Although it was more complex then I first envisioned, it also delivered everything that I expected in terms of equipping me with the tools and skills to go out and practice as a confident and competent chiropractor.

Jacob Augimeri – Macquarie Graduate

Olivia Thompson – Macquarie Graduate

Jacob Augimeri & Olivia Thompson

What was the best aspect of the uni experience? For me, it was the supportive mentorship provided by teaching staff. I had Michael Swain and Aron Downie as my supervisors and their leadership particularly facilitated extensive growth in my education and made the whole experience amazing.

L-R: Michael Swain, Annika Young, Aron Downie

Annika Young – Macquarie graduate

Macquarie graduate Hilary Conroy

W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U

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RESEARCH NEWS

Abstracts

impact of surgical timing on functional outcome. Spine, March 22, 2019

SMT IS BETTER IN THE SHORT-TERM… BUT INFORMED CONSENT IS A MUST

Systematic Reviews

For the treatment of chronic low back pain, researchers evaluated the benefits and harms of spinal manipulative therapy (SMT). Studies were considered eligible if they included adults (≥18 years) and if pain lasted more than three months for more than 50% of the study population. Studies that examined sciatica exclusively, like grey literature, were excluded. Forty-seven randomized controlled trials were identified, including a total of 9211 participants who were medium age (35-60 years) on average. According to this systematic review and meta-analysis of randomised controlled trials, SMT produces similar effects to recommended therapies for chronic low back pain, while SMT appears to be better for improving function in the short term than nonrecommended interventions. Clinicians should inform their patients about the potential risks of SMT-related adverse events. Musculoskeletalrelated, transient in nature, and of mild to moderate severity were most of the observed adverse events. Rubinstein SM, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: Systematic review and meta-analysis of randomised controlled trials. BMJ, March 14, 2019 INTERESTING RESEARCH ON THE DELAY OF SURGERY WHEN MOTOR DEFICITS ARE PRESENT In this retrospective cohort study, researchers evaluated the impact of time to surgery on their functional outcome in patients with motor deficits (MDs). In a group of patients with acute paresis in a “real-world” setting, the current single-center study presents results of emergency surgery for lumbar disc herniation (LDH). From January 2013 to December 2015, a total of 330 patients with acute paresis caused by LDH acutely referred to the department and surgically treated using microsurgical discectomy were involved. According to findings, body mass index, preoperative MRCgrade, and duration of MDs were identified as significant predictors for paresis recovery at all follow-ups with significant impact on reported outcomes including sciatica and/or dermatomal sensory deficits. In view of the higher neurological recovery rates of acute moderate/ severe MDs, the primary option should be immediate surgery. Petr O, et al. Immediate vs delayed surgical treatment of lumbar disc herniation for acute motor deficits: The

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CA NEWS JUNE 2019

PLATELET-RICH-PLASMA NOT AS GOOD AS ORIGINALLY THOUGHT? Via performing this systematic review of randomized controlled trials, researchers appraised the utility of platelet-rich plasma (PRP) for nonoperative treatment of rotator cuff disease. The inclusion criteria were met by 5 randomized controlled trials including with 108 patients treated with PRP and 106 treated with a control. As per the limited available evidence, no possible benefit of PRP injections in the short term was evident. No superior functional outcomes, pain scores, or range of motion were achieved with PRP when directly compared with exercise therapy. Hurley ET, et al. Nonoperative treatment of rotator cuff disease with plateletrich plasma: A systematic review of randomized controlled trials. Arthroscopy, April 19, 2019 DO STATINS HELP PREVENTING ISCHAEMIC STROKE… MORE MODESTY Researchers summarized the evidence of statin use in secondary prevention for ischemic stroke patients by comparing the benefits and harms of different statins. For this purpose, they analyzed data from nine trials have been identified (n=10,741 patients). The median follow-up period was 2.5 years. Evidence strongly suggested that a reduction in the absolute risk of ischemic strokes and cardiovascular events was linked to statins. There were modest differences in effects between statins, signaling potential therapeutic equivalence. Tramacere I, et al Comparison of statins for secondary prevention in patients with ischemic stroke or transient ischemic attack: A systematic review and network meta-analysis. BMC Medicine, March 28, 2019 THE EFFECTS OF HERBS AND SPICES ON BLOOD PRESSURE: Researchers analyzed data from nine relevant randomized, controlled trials that were identified via a literature search of the Ovid Medline, Embase, Biological abstracts, CINAHL and Cochrane Collaboration databases to determine the impact of herbs and spices on blood pressure in normotensive,

pre-hypertensive, and hypertensive individuals. Statistically significant outcomes were reported in three of the nine studies, including one of the two studies on hypertensive participants and two of the six studies on pre-hypertensive participants. In the remaining study involving normotensive individuals, no change in blood pressure was evident. In all, the investigators found evidence that was suggestive of the ability of certain herbs and spices to attenuate blood pressure in a hypertensive and prehypertensive population, without possibly resulting in hypotension in a normotensive population. Effects of herbs and spices on blood pressure: A systematic literature review of randomised controlled trials. Journal of Hypertension, March 08, 2019

Info Bites DENTISTS GET MORE NECK PROBLEMS THAN THE GENERAL POPULATION… A SURPRISE? In this retrospective nationwide populationbased study, researchers ascertained if the risk of a cervical herniated intervertebral disc (C-HIVD) in dentists was higher compared to the general population and other health care providers. According to results, dentists had a lower prevalence of mental disorders, diabetes mellitus, chronic obstructive pulmonary disease, malignancy, stroke, and renal disease, but the prevalence of hypertension and hyperlipidemia was higher than the general population. During the 5-year follow-up period, dentists had a cumulative incidence rate of 1.1% for C-HIVD. The authors concluded that younger dentists had a higher risk trend than members of the general population to develop C-HIVD Huang CC, et al. Risk for cervical herniated intervertebral disc in dentists: A nationwide population-based study. BMC Musculoskeletal Disorders, May 07, 2019 MEASLES, MUMPS, RUBELLA VACCINATION AND ANOTHER STUDY SHOWS THAT THERE IS NO INCREASED RISK OF AUTISM In this nationwide cohort study involving 657,461 children born in Denmark, researchers ascertained if the risk for autism is increased after receiving the measles, mumps, rubella (MMR) vaccine in children, subgroups of children, or time periods after vaccination. There were 6,517 children diagnosed with autism during 5,025,754 person-years of follow-up. The investigation strongly supports that MMR vaccination does not


RESEARCH NEWS increase autism risk, does not trigger autism in susceptible children, and is not associated with post-vaccination clustering of autism cases. It adds significant additional statistical power to previous studies and addresses susceptible subgroup hypotheses and case clustering. A fully adjusted autism hazard ratio of 0.93 was seen when comparing MMRvaccinated with MMR-unvaccinated children. Hviid A, et al. Measles, mumps, rubella vaccination and autism: A nationwide cohort study. Annals of Internal Medicine, May 03, 2019 NOW THAT’S INTERESTING… BREECH PRESENTATION IS ASSOCIATED WITH LOWER ADOLESCENT TIBIAL BONE STRENGTH. In this study involving nearly 2,000 participants from the UK prospective birth cohort, researchers assessed associations between breech presentation at onset of labor with tibia and hip bone outcomes at 17 years of age among participants. They noted an association of breech presentation (n=102) with lower tibial cortical bone mineral content (BMC; − 0.14SD), cross-sectional area (CSA; − 0.12SD), bone mineral density (− 0.16SD), periosteal circumference (− 0.14SD), and cross-sectional moment of inertia (− 0.11SD) in models adjusted for sex, age, maternal education, smoking, parity, and age, singleton/ multiple births. They also observed a relation of breech presentation with lower hip CSA (− 0.24SD, − 0.43 to 0.00) in females only. Prenatal skeletal loading may exert longlasting effects on skeletal size and strength but require replication, according to findings. Tobias JH, et al. Breech presentation is associated with lower adolescent tibial bone strength. Osteoporosis International, April 26, 2019 SMT EFFECTS IN AUTONOMIC REGULATION AND EXERCISE PERFORMANCE IN RECREATIONAL HEALTHY ATHLETES Investigators quantified the acute impacts of spinal manipulative therapy (SMT) on performance and autonomic modulation in recreational athletes in this randomized, double-blind, parallel groups, sham-controlled trial. In response to actual vs sham SMT, a significant and lower value of a marker of sympathetic modulation (the stress score) was observed. With actual SMT, they noted a trend toward a significant and likely lower sympathetic: parasympathetic ratio and a likely higher natural logarithm of the root-meansquare differences of successive heartbeat intervals. They also found a significantly lower mean power output during the time trial with

actual vs sham SMT. Induction of an acute shift toward parasympathetic dominance and slight impaired performance in recreational healthy athletes were reported with a single pre-exercise SMT session. Valenzuela PL, et al. Spinal manipulative therapy effects in autonomic regulation and exercise performance in recreational healthy athletes: A randomized controlled trial. Spine, April 23, 2019 THE RISK OF RE-OPERATION ON AN ADJACENT SEGMENT AFTER DECOMPRESSION-ONLY SURGERY FOR LUMBAR SPINAL STENOSIS IS 3.9 TIMES HIGHER IF. In this retrospective study of 235 consecutive patients who had undergone decompressiononly surgery for lumbar spinal stenosis, researchers investigated how developmental spinal stenosis (DSS) influence the risk of re-operation at an adjacent level. Re-operation at an adjacent segment was done in 21.7%. In the multivariate regression model controlled for other confounders, DSS was identified as a poor prognostic indicator that can be identified prior to index decompression surgery. They identified 3.9 times higher likelihood to undergo future surgery at an adjacent level among patients with DSS who have undergone lumbar spinal decompression. Cheung PWH, et al. The influence of developmental spinal stenosis on the risk of re-operation on an adjacent segment after decompression-only surgery for lumbar spinal stenosis. Th e Bone & Joint Journal, February 15, 2019 HOW LONG DOES A HIP REPLACEMENT LAST? Researchers conducted a systematic review and meta-analysis with a search of MEDLINE and Embase from the start of records to September 12, 2017, to answer the question: how long does a hip replacement last?. Articles reporting 15-year survival of primary, conventional total hip replacement [one of the most common and effective forms of surgery] constructs in osteoarthritis patients were included. Data reported that the 25-year pooled survival of hip replacements from case series was 77·6% and from joint replacement registries was 57·9%. If estimates from national registries are less likely to be biased, patients and surgeons can expect a hip replacement in approximately 58% of patients to last 25 years. Evans JT, et al. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. The Lancet, February 19, 2019

THE PROJECTED BURDEN OF PRIMARY TOTAL KNEE AND HIP REPLACEMENT FOR OSTEOARTHRITIS IN AUSTRALIA TO THE YEAR 2030 IS $5.3 BILLION Data collected from the Australian Orthopaedic Association National Joint Replacement Registry was evaluated to prognosticate the burden of primary total knee (TKR) and hip replacements (THR) performed for osteoarthritis (OA) in Australia to the year 2030, and also to illustrate the influence of contrasting obesity scenarios on TKR burden. They projected the procedure rates as per 2 scenarios viz, constant rate of surgery from 2013 onwards and continued growth in surgery rates based on 2003–2013 growth. They calculated a rise by 276% and 208% by 2030, in the incidence of TKR and THR for OA, respectively. They estimated the total cost to the healthcare system, $AUD5.32 billion, of which $AUD3.54 billion linked to the private sector. Ackerman IN, et al. The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030. BMC Musculoskeletal Disorders, February 25, 2019 IMAGING VS NO IMAGING FOR LOW BACK PAIN: A SYSTEMATIC REVIEW, MEASURING COSTS, HEALTHCARE UTILIZATION AND ABSENCE FROM WORK. Researchers examined the data to analyze the consequences of imaging (X-ray, CT, and MRI) vs no imaging in case of low back pain (LBP). They observed that early MRI may lead to an increase in costs. They found an association of performing MRI or imaging (MRI or CT) with an improvement in healthcare utilization like future injections, surgery, medication, etc. No significant difference was noticed between X-ray or MRI groups compared with non-imaging groups on absence from work. Overall, they concluded a relation of imaging in LBP with higher medical costs, expanded healthcare utilization and more absence from work. Lemmers GPG, et al. Imaging vs no imaging for low back pain: A systematic review, measuring costs, healthcare utilization and absence from work. European Spine Journal, February 26, 2019 HIGHER PREVALENCE OF CONCOMITANT SHOULDER LABRAL TEARS IN PATIENTS WITH FEMOROACETABULAR IMPINGEMENT Researchers examined 1644 cases who underwent femoroacetabular osteoplasty (FAO) and labrum repair and 1055 subjects

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RESEARCH NEWS who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction to estimate the prevalence of concomitant symptomatic glenoid labral tears in femoroacetabular impingement (FAI) cases vs candidates with ACL reconstruction. They observed subjects in the FAO group with slightly older age (36.3 years vs 32.3 years) and more commonly female in the FAO group (58.0%) compared with those in the ACL group (48.9%). They recorded 12.0% prevalence of shoulder labral tear for the FAO group vs 3.3% for the ACL group. They observed shoulder labral tears to be traumatic in only 43.4% of cases in the FAO group when compared with 80.0% of cases in the ACL group. They found an association between acetabular labral tear caused by FAI and shoulder labral lesions. Vahedi H, et al. Higher prevalence of concomitant shoulder labral tears in patients with femoroacetabular impingement. Arthroscopy, March 14, 2019 IS THERE A DIFFERENCE IN CERVICAL SPINE MUSCULAR ENDURANCE PERFORMANCE IN WOMEN WITH AND WITHOUT MIGRAINE? In this prospective cohort study of 261 healthy (noninjured) runners over a period of 14 weeks, researchers examined the association between a change in weekly running distance and running-related injury (RRI). Further, they investigated whether the running schedule the runner follows modifies this association. Runners who increased their weekly running distances by 20% to 60% had significantly more injuries during the 21 days into the study period compared to those who increased their distances by less than 20%. In this Cross-sectional, controlled laboratory study, authors quantified the variations in neck flexor and extensor muscle endurance between females with (n=26) and without (n=26) migraine. They reported a lower holding time for both neck extensor endurance and neck flexor endurance in individuals with migraine vs the controls. They recorded 35.0 s, the median neck flexor holding time for the migraine group in comparison to 60.5 s for the control group. They found that the migraine group maintained the neck extensor endurance test position for a median of 166.5 s when compared to 290.5 s for the control group. They noted a similar level of neck pain during the endurance tests in both groups. Although, candidates in the migraine group listed pain in the head only, during testing. Florencio LL, et al. Cervical muscular endurance performance in women

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CA NEWS JUNE 2019

with and without migraine. Journal of Orthopaedic & Sports Physical Therapy, March 28, 2019 IS THERE A BETTER WAY TO TEACH PATIENTS TO BRACE THE SPINE? READ ON... Performing this experimental and comparative study, researchers compared the increase in lumbar stiffness with two potential interventions, actively increasing abdominal muscle activity, either through the abdominal drawing-in maneuver (ADIM) or bracing, vs passively increasing lumbar stiffness using a lumbosacral orthosis (LSO). In 25 healthy individuals, they estimated lumbar stiffness, a surrogate measure of lumbar stability, during 7 trunk perturbation conditions: (1) control, (2) ADIM, (3) bracing at 5% of right external oblique maximal voluntary activation (5% bracing), (4) bracing at 10% of right external oblique maximal voluntary activation (10% bracing), (5) LSO, (6) LSO plus 5% bracing, and (7) LSO plus 10% bracing. As bracing and ADIM were performed at the same overall abdominal activation levels (5% and 10% maximal voluntary activation), they produced comparable lumbar stiffness. Observations revealed the independent effects of bracing and LSO. This suggests that in some circumstances, these interventions could be combined. Larivière C, et al. Maintaining lumbar spine stability: A study of the specific and combined effects of abdominal activation and lumbosacral orthosis on lumbar intrinsic stiffness. Journal of Orthopaedic & Sports Physical Therapy, April 02, 2019 DOES HAVING A “TENNIS ELBOW” IMPACT ON THE SHOULDER… OR VICE VERSA? A total of 51 cases with lateral epicondylalgia (LE) and 51 age-matched controls were examined to study the scapular position and upper extremity muscle strength in subjects with LE vs controls. A higher percentage of candidates with scapular asymmetry was observed in the cases when compared to the controls. They found that the involved side regarding shoulder external rotation among the cases was significantly weaker as compared to the controls. In terms of shoulder abduction, external rotation, and internal rotation, the involved side of subjects with LE was significantly weaker than the uninvolved side. They recorded a significantly greater upper trapezius (UT)/middle trapezius (MT) ratio on the nondominant side of the controls as compared to that on the involved side of the LE cases.

Ucurum SG, et al. Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: A case-control study. Journal of Shoulder and Elbow Surgery, March 28, 2019 CHANGES IN PRACTICE AMONG PHYSICIANS WITH MALPRACTICE CLAIMS. Doctors with poor malpractice liability records could be a risk to the safety of patients and the fact that such doctors often relocate for a fresh start is cause for concern, so researchers assessed if, how, and where they continue to practice. Investigators found that doctors with numerous claims of malpractice against them were no more likely to relocate vs those without claims but were more likely to discontinue practicing medicine or change to smaller practices. Studdert DM, et al. Changes in practice among physicians with malpractice claims. New England Journal of Medicine, March 29, 2019 LOW BACK PAIN PRECEDES THE DEVELOPMENT OF NEW KNEE PAIN IN THE ELDERLY POPULATION. Researchers examined how knee and low back pain/disabilities are correlated in this longitudinal cohort study. They also developed a predictive score that may assist in the identification of people who are likely to develop new knee pain within 5 years. At the first surveillance, a total of 5,932 people aged ≥ 50 years agreed to participate in this study from 2007 to 2010. Then, these respondents of the first survey were sent a second survey in 2015, and 5,576 participants returned the form (94.0% response). According to results from multivariate analyses, significant risk factors for the development of new knee pain in people aged ≥ 50 years who had no, or negligible, knee symptoms were older age, female sex, higher body mass index, lower mental health score, weight increase, and higher low back pain/disability score. The developed predictive score included low back pain/disability score and indicated that the risk of developing new knee pain within 5 years ranged from 11.0% to 63.2%, depending on the total score. Ito H, et al Low back pain precedes the development of new knee pain in the elderly population; A novel predictive score from a longitudinal cohort study. Arthritis Research & Therapy, April 18, 2019


CLASSIFIEDS

And Furthermore...

FOOD PORTIONS JUST KEEP GETTING BIGGER IN FAST FOOD MENUS In this study, researchers reported on the changes in fast-food menu offerings over

Lopez PD, et al. The effect of vegan diets on blood pressure in adults: A meta-analysis of randomized, controlled trials. American Journal of Medicine, March 08, 2019

SUGAR SWEETENED BEVERAGES AND FRUIT JUICE INTAKE IS RELATED TO

30 years - including food variety (number of items as a proxy), portion size, energy,

NOT GOOD NEWS (MODESTLY) ON DRINKING LOTS OF COFFEE FOR A

GOUT

energy density, and selected micronutrients

LONG TIME

(sodium, calcium, and iron as percent

Researchers used data from the UK

In this systematic review and meta-analysis of prospective cohort studies, researchers examined the relation of important food sources of fructose-containing sugars with incident gout. A total of 154,289 participants with 1,761 incident cases of gout were included in this analysis. Using the Grading of Recommendations Assessment, Development and Evaluation system, the overall certainty of the evidence was assessed. No reports of incident hyperuricemia were found, and no significant link between fruit intake and gout was identified. The strongest evidence was for the adverse association with intake of sugar-sweetened beverage (SSB; moderate certainty), and the weakest evidence was for the adverse association with intake of fruit juice (very low certainty) and lack of association with intake of fruit (very low certainty). The authors concluded that SSB and fruit juice intake are adversely linked to incident gout, which does not appear to extend to fruit intake. Ayoub-Charette S, et al. Important food sources of fructose-containing sugars and incident gout: A systematic review and meta-analysis of prospective cohort studies. BMJ Open, May 08, 2019 MORE BAD NEWS ON ARTIFICIAL SWEETENERS. Researchers investigated how selfreported consumption of artificially sweetened beverages (ASB) is associated with stroke and its subtypes, coronary heart disease, and all-cause mortality in a cohort of postmenopausal US women. Outcomes revealed an increased risk of stroke, particularly small artery occlusion subtype, coronary heart disease, and allcause mortality in correlation with higher intake of ASB. Mossavar-Rahmani Y, et al. Artificially sweetened beverages and stroke, coronary heart disease, and all-cause mortality in the Women’s Health Initiative. Stroke, March 12, 2019

daily value) - and compared changes over time across menu categories (ie, entrées, sides, and desserts). Data regarding the

disease (CVD) risk varied with CYP1A2

dessert menu item for 1986, 1991, and 2016 for 10 popular fast-food restaurants displayed a combined increase by 226%. They noted a significant increase in the

(a functional variant at cytochrome P450 1A2) genotype or a genetic score for caffeine metabolism (caffeine-GS). They analyzed data for 347,077 individuals, with

portion sizes of entrées (13 g/decade)

8,368 incident CVD cases. An elevated

and desserts (24 g/decade) - but not of

CVD risk was reported for non-drinkers,

sides - with a significant increase in the energy (kilocalories) and sodium of items in all three menu categories. These findings suggested broadly detrimental changes in fast-food restaurant offerings over a 30year span. Findings, thus, call for effective strategies to help consumers reduce energy intake from fast-food restaurants to better dietary-related health issues in the United States. McCrory MA, et al. Fast-food offerings in the United States in 1986, 1991, and 2016 show large increases in food variety, portion size, dietary energy, and selected micronutrients. Journal of the Academy of Nutrition and Dietetics, February 28, 2019

drinkers of decaffeinated coffee, and those who reported drinking >6 cups/ day vs those drinking 1–2 cups/day (increase in odds by 11%, 7%, and 22%, respectively). A modest increase in CVD risk was observed in association with heavy coffee consumption, but genetic variants affecting caffeine metabolism had no impact on this link. Zhou A, et al. Long-term coffee consumption, caffeine metabolism genetics, and risk of cardiovascular disease: A prospective analysis of up to 347,077 individuals and 8,368 cases. American Journal of Clinical Nutrition, March 12, 2019

Classifieds

NO GREAT ADVANTAGE ON BEING VEGAN WHEN IT COMES TO BLOOD PRESSURE In this randomized, controlled clinical trial, a total of 983 candidates aged ≥18 years and older were studied to investigate the influence of vegan diets on blood pressure in adults. Researchers found no significant impact of a vegan diet in systolic (−1.33 mmHg) or diastolic (−1.21 mmHg) blood pressure vs less restrictive diets, but mean reductions in the systolic (−4.10 mmHg) and diastolic (−4.01 mmHg) blood pressures were noted with the vegan diet in a pre-specified subgroup analysis of studies with baseline systolic blood pressure ≥ 130 mmHg. Overall, they recorded similar changes in blood pressure resulting from a vegan diet without caloric restrictions vs societies and portion-controlled diets.

examine whether the link between habitual coffee consumption and cardiovascular

number of fast-food entrées, sides, and

dietary strategies suggested by medical

Biobank, as well as logistic regression, to

ASSOCIATES REQUIRED QLD – Brisbane: An exciting opportunity has become available for a patient-focused, motivated chiropractor with excellent manual adjusting skills. Our practice is a multidisciplinary, holistic health clinic located in the inner-city Brisbane suburb of Newstead with a rapidly expanding patient base. If you would like more information or would like to apply for the position please give Dr Katrine a call on 0405 456 589 or email hello@elitetherapy. com.au SA – Klemzig: We are looking for an enthusiastic Associate to join our team and take over from our current associate and their patient base. The Principal chiro is at capacity and the clinic has potential for growth for the right person. We are looking for someone

W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U

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CLASSIFIEDS who is confident in manual adjusting; compassionate; has good communication skills; a love of people and is a fun, energetic team player. If you are looking for a clinic that is patient focused, delivers high quality care, and believes in taking the time to build strong relationships with patients, this could be the practice for you. We are offering a very attractive remuneration package. If you are interested, please send us an email about why you would like this role. We look forward to hearing from you. melschultz81@hotmail.com

continuing to expand due to our rapid growth with patients, medical referrers, networks and an excellent community reputation. We offer an attractive salary with great performance incentive so that you will be rewarded for your hard work. If you are a young, energetic practitioner looking for an inspiring practice to leap frog years in your learning curve then this is the place for you. Learn more https:// thisislifewellness.lpages.co/new_chiropractor or contact Michaela Menichelli hello@ thisislifewellness.com.au or (03) 9531 5050

QLD – Gold Coast: LOCUM REQUIRED: Gold Coast clinic seeking competent locum for 2 weeks in mid-July and 3 weeks midAugust. Would also suit associate to start earlier and continue on in the practice. A range of treatment approaches consistent with evidence based and outcome assessed care preferred. 0405 388 720 currumbinchiro@gmail.com

QLD – North Lakes: Hear that… that’s opportunity knocking! We are looking for a motivated, driven and entrepreneurial Chiropractor to join our long established business as our Principal Chiropractor, with the opportunity to buy into the practice within 12 months, if it’s the right fit. Our practice is located halfway between Brisbane and the Sunshine Coast and the location offers a great lifestyle. With consistent high numbers of new clients per week (25–40), building a caseload quickly is not a problem. The right Chiropractor will be experienced, have a business brain, have an interest in mentoring other Chiropractors in the team, be able to lead by example, be a team player, have a passion for family health to grow the Chiropractic side of the business and must be looking for a stable, long term role with us. Opportunities like these don’t come around too often, so what are you waiting for? Tell us about your experience and why you would be the right Principal Chiropractor for our practice. Email your expression of interest to chiroassociatebris@gmail.com We can’t wait to meet you.

NSW – Sydney: Seeking enthusiastic chiropractors – graduates welcome to apply! Fresh job alert for full and part-time positions in Health Space Mosman! We are a fun, active and passionate team with a huge focus on mentoring, coaching and learning. Take advantage of our multiple network partnerships for free or discounted exercise and health treatments! 17 clinics across Sydney. We are looking for passionate and enthusiastic chiropractors to join one of Sydney’s largest health care groups, practicing in a multidisciplinary clinic. We are a family and treat each other as such, every effort will be made to ensure you are happy and successful. Find out more about us on www.healthspaceclinics. com.au If you want to join the Health Space family email your resume to careers@ healthspaceclinics.com.au NSW – Central Coast: Join our long-standing reputable chiropractic centre on the beautiful Central Coast. Looking for an associate to replace our current associate who is moving. Essential skills include proficiency in manual adjustments and soft tissue techniques with great communication and time management abilities. Desired skills also include drop piece, activator and dry needling. Please email: jennchiro@hotmail.com VIC – Elwood: Are you a dynamic and motivated Chiropractor with a desire to excel in private practice? We are a very well established and progressive practice known for delivering exceptional patient outcomes in a supportive and family focused environment. With over 33 years of history we are

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CA NEWS JUNE 2019

QLD – Gold Coast: Join our highly regarded evidence-based practice. Successful applicant will have high ethical standards, positive attitude and friendly personality. Willingness to interact and inter-refer with other healthcare professionals is important. The principal chiropractor will be available for mentoring. New graduates are encouraged to apply. 12-month income expectation $100k+. Phone: 0413 461 849 or email: amfell@ hotmail.com VIC – Caulfield: Looking for a vibrant Chiropractor to join our team in a permanent Part Time Employee position (Salary + Annual Leave + Super + Performance Bonuses). This position comes with mentoring (over 11yrs experience,) marketing, a supportive team and great culture! Go to this link for more information: https:// thechirotree.lpages.co/chiro-job-ad/ or email kate@thechirotree.com.au

BUSINESSES FOR SALE FOR SALE QLD – Sunshine Coast: Immediate opportunity exists on the beautiful Sunshine Coast. Open plan adjusting, private consultation room, generous reception space. Onsite visitor and dedicated client parking a bonus in this modern ground floor health precinct. Main road location, terrific traffic exposure and a strong online presence. Consistent growth since opening. Plenty of room for future growth as owners practice part time. For more information email jacobjlong@hotmail.com or call 0474 483 133. NSW – Sydney: Long running, established chiropractic clinic in the heart of Sydney CBD, conveniently located near Town Hall station. Current owner (sole practitioner) wishes to retire, is willing to stay on for a handover period and has priced the business accordingly. Three treatment rooms with air conditioning, wash basin and waiting room. Practitioner seeking to hand over to caring and responsible person. As the Clinic Manager, a clinician and lessee, you’ll enjoy the company of other practitioners. Two rooms are already sub-let to an Acupuncturist and a Chiropractor (who run their businesses independently), lowering the overheads for your own practice. Owner currently operating his practice part-time. Opportunity to grow clinic revenue, through extending operating hours to include Saturdays and promote online (currently unlisted). Suits a new chiropractor / osteopath or clinician seeking a convenient CBD location. Price open for negotiation. For more information please email: cssr.sydney@gmail.com or call (02) 9590 3650

BUSINESSES WANTED TO BUY NSW – Sydney: Practice-wanted to BUY, Sydney, city or suburban. Call S Kelly 0413 131 238 or email cjslkelly@ozemail.com.au FOR SALE: Australia Wide: New Chiropractic tables and supplies for all your practice needs. Australia’s largest supplier of treatable tables allowing Everfit to provide the lowest prices. FREE shipping Australia wide. Visit us today http://www.everfithealthcare.com.au/ or call 1800 908 903