CA News September 2020

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Bruce Walker Interview Self Reflection in CPD Electronic Health Records

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Professor Rod Bonello

BSC(SYD), DO, DC(SCC), MHA(UNSW), FRCC The effects of COVID-19 Impact on chiropractic practice 2020 will surely be remembered as a most unusual year. Some of the behavioural changes necessitated by the spread of the corona virus will probably last for years simple things like handshaking and public displays of affection, the ubiquitous presence of hand sanitiser and the style of coughing. But what is the impact on chiropractors, their businesses and our patients? In March, most chiropractors reported a drop in consultation numbers as patients increasingly chose to self-isolate. As the weeks passed the majority of practices recovered weekly patient numbers at least to some extent as their clients returned to treatment. COVID or not, patients still had their chronic musculoskeletal problems and continued to suffer acute injuries that required attention. The difference, post February 2020, was that consultation times were staggered to minimise waiting room proximity and allow for deep cleaning between patients. Telehealth consultations have been a new area of endeavour and these has been very useful for monitoring patients, guiding rehabilitation activities and counseling. Of course, chiropractic is not best suited to remote treatment but for many it has helped fill the gaps. And chiropractors have been active in supporting public health initiatives and educating patients on limiting the spread of the virus in the community. In June, Johnson et al (2020) reported the findings of a survey of African, Asian, Eastern Mediterranean, European, Latin American,

The evolution of Spineweek into SpineOnline was a prime example of where the solution led to a result which was probably superior in many ways to the original offering.

North American and Pacific chiropractors. She found that with respect to COVID-19, chiropractors… “recognized and abided by changing governmental regulations... observed their patients experience increased stress and mental health concerns… adopted innovative strategies, such as telehealth to do outreach, communicate with, and provide care for patients... abided by national and WHO recommendations... they adopted creative strategies to maintain connectivity with patients through a people-centered, integrated, and collaborative approach.”

We can all be proud of the sterling manner in which the chiropractic profession has handled itself during this pandemic. We have modified practice, educated patients and adapted to be genuinely supportive to our clients and the community at large. I am especially proud of our members. Kind regards and stay safe

Rod Bonello

In speaking with several dozen CA members over the last few months our experience is identical. Impact on our chiropractic schools Universities have required that students stay away from campus for lengthy periods this year. While theory classes have in most instances successfully been moved on-line, practical classes are another matter. Special accommodations have been made with the adoption of strategies such as intensive block sessions and make-up classes. The course accreditation authorities and Registration Board will need to be assured that minimum standards have not been breached.

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

Reference: Johnson CD, Green BN, Konarski-Hart KK, et al. Response of Practicing Chiropractors during the Early Phase of the COVID-19 Pandemic: A Descriptive Report [published online ahead of print, 2020 Jun 13]. J Manipulative Physio Ther. 2020;S0161-4754(20)30122-6. doi:10.1016/j. jmpt.2020.05.001

Loss of connectedness Just as our patients have suffered higher levels of personal stress due to work, family and social disruption, chiropractors have been prevented from engaging with others in supportive fellowship. We have had to develop innovative solutions to combat this loss.

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Interview with Professor Bruce Walker By: Matthew Bulman BHSc, MChiro

Professor Bruce Walker, AM, DC, MPH, DrPH, FRCC (UK) from Murdoch University should require no introduction to Chiropractic Australia members. Professor Walker has a long and illustrious career in clinical practice and academia and has received multiple awards and recognitions for his work, including being admitted as a Member of the Order of Australia for his service to the chiropractic profession. Recently, Professor Walker has been honoured by the Board of the Chiropractic Australia Research Foundation who have named a PhD Scholarship after him. The “Walker Chiropractic Australia Research Foundation PhD Scholarship” will be awarded to the highest ranked applicant each year when their PhD proposal is in the area of Professor Walker’s research. CA Research Foundation’s next round of PhD scholarships will be announced soon, and this scholarship will be awarded if a relevant application is successful. Professor Walker has helped lead the profession over many years and has, more recently, announced his imminent retirement. He has been kind enough to take some time out of his busy schedule to answer a few questions for the readers of our newsletter.

You have had a long and illustrious career both in private practice and academia. What are some of the highlights for you? The privilege of being in full time practice for 30 years allowed me to treat approximately 35,000 people and deliver about 100,000 consultations. I hope and trust that I was able to help the majority of those people with their musculoskeletal problems. I was a relative late comer to academia, but during my 15 years at Murdoch University, I was fortunate to pass the 100 peer-review article milestone and have my work cited over 3500 times. Being Head of Chiropractic for 5 years allowed me to be an agent for change and inculcate evidencebased practice into the teaching program. Moreover, working with a great team of likeminded academics was a true privilege. Being honoured with an AM was also a great privilege and more recently having a PhD scholar-



ship named after me by Chiropractic Australia Research Fund was totally unexpected and gave me a great sense of pride.

You have announced your retirement. Can you outline why you are making this decision? As mentioned in your introduction, my retirement was publicly announced some time ago and will occur in November. After a gap year following Year 12 at high school, I enrolled in chiropractic in 1972. I have been a chiropractor for 45 years and reached a stage in life where I wish to explore other things. The profession has given me a vocation that has been rich and rewarding. It has not been without its challenges but overall, I have been very fortunate to have chosen chiropractic as my career. In the words of Joe Walsh, “Life’s been good to me so far”!

You are Editor in Chief of Chiropractic and Manual Therapies, which was previously the journal Chiropractic and Osteopathy. Can you tell us about some of the history of the journal, its highlights along the way, and the recent establishment of an Impact Factor? I started the journal in 1992 as COMSIG Review (initially COCA’s magazine) with a small team of intellectual chiropractors and osteopaths, it then changed its name to Australasian Chiropractic & Osteopathy and later to Chiropractic & Osteopathy and became a fully peer reviewed journal. It was the flagship journal of COCA, now Chiropractic Australia. At a point in time we were also joined by the UK Royal College of Chiropractors journal, which ceased publication and became “part of” C&MT. In 2005 we moved to an online, free full text format with the publisher BioMed Central, now owned by Springer NATURE. Over the next 15 years we set out a plan to achieve many goals including MEDLINE Listing and an Impact factor. We also once again changed our name to Chiropractic & Manual Therapies to better reflect our charter. We did achieve MEDLINE listing and in June this year an Impact Factor. The journal debuted with an Impact Factor of 1.5 which is the highest IF metric for a chiropractic journal in the world. The journal has been accessed over 3.5 million times since 2005. This success has been due to the many authors who submitted articles, the outstanding team of editors and also the support of our four joint venture society partners: Chiropractic Australia, NIKKB (Denmark), European Chiropractors Union (via their academic arm EAC) and the Royal College of Chiropractors (UK). The profession should be

very proud of the journal and under the new leadership of Associate Professor Iben Axen and Professor Simon French as Co-Editors in Chief it will achieve bigger and better things.

I recall your commentary, The New Chiropractic, which was the FG Roberts Memorial Address in October 2015, and was then published in Chiropractic and Manual Therapies. Your address included a 10-point plan. (See accompanying article.) What progress have we made these past 5 years? And what is your assessment of the profession now? This is a good question and I encourage others to make judgements about these 10 recommendations 5 years on. They still hold true today. Progress has been agonisingly slow, but I do predict that within 50 years the profession will be vastly different to today. Anecdotally, I believe there has been a greater shift towards evidence-based practice despite a small rear-guard action by fundamentalists within the profession. Many of our new graduates will witness these positive changes over time.

If you could give one piece of advice to a chiropractor commencing their career at this point in time, what would you recommend to them? Here are two: a) Try to join an evidence-based practice and engage with an EBP mentor. b) Do not over service or under service patients.

If you could answer one scientific question of relevance to the chiropractic community, what would that be? What are the markers that predict response to spinal manipulation for spinal pain?

Regarding research, where is the profession currently at when it comes to developing its research capacity? And what is the next landmark we need to get to? The profession is currently divided, as it has

INTERVIEW been for many years. However, by and large the chiropractic profession makes a substantial difference to humanity by relieving pain and disability. It will continue to do so. Regarding research, in the 10 years between 2010-2019, research involving chiropractic sees 3276 articles documented in PUBMED, for physiotherapy there are 173,000 articles or over 50 times as much research published. Clearly, there is an urgent need for much more research to be initiated by the chiropractic profession. The results of this research will inform practice for years to come and boost our professions international standing and reputation.

Who are some of the people along the way who have helped you in your career? There are too many to mention, but first and foremost my GP wife, Dr Alison Hogg. In my early career, my first mentor was David Hobbs DC who mentored me in practice, in addition

I owe a lot to John Reggars, Simon French, Rachelle Buchbinder, William Grant, Jay Triano and more latterly, Charlotte LeboeufYde, Stan Innes, Ken Young, Jeff Hebert and Iben Axen. They are all inspirational people. Apologies to the very many I have left out.

What do you hope to be most remembered for in your career?

You helped to establish the Chiropractic Australia Research Foundation [CARF] (formerly COCA Research Ltd). Can you tell us about its establishment, and some of the highlights along the way? What research goals would you like to see the Foundation strive towards? Several of us saw the need to establish a research fund in Australia that was focused on spinal pain and disability. Early on we decided that the best investment for the future was to support chiropractic PhD students, so that is where CARF has concentrated. CARF is in good hands and I think their focus is still well placed. We need to build the academic research pool.

My commitment to chiropractic via the creation of COCA (now Chiropractic Australia), the promotion of evidence-based practice and the establishment of the journal Chiropractic & Manual Therapies.

Is there anything else you wish to add? I encourage all chiropractors to continue serving the public and putting their patients first. I also encourage chiropractors to volunteer for the advancement of the profession, to acknowledge good practice when they see it and to call out poor practice when they witness that. I encourage all to embrace the three elements of evidence-based practice, i.e. best scientific evidence, clinical expertise and patient values and circumstances. Finally, I ask that chiropractors dig deep and fund meaningful research.

Bruce Walker’s FG Robert’s Address (including his 10 point plan) By: Matthew Pope (reproduced as it appeared in COCA News – December 2015) On Saturday 10th October, Associate Professor Bruce Walker delivered the FG Roberts address to open COCA’s 11th Biennial Conference in Melbourne. He went through the long, diverse and at times checkered history of the chiropractic profession and came to where we are today. The good: our contribution through aiding pain relief in society, no small feat and one that should not be downplayed regarding the effects that we can have. The bad: sections of the profession have an unhealthy disregard for evidence-based practice, the natural history of benign and self-limiting conditions, public anti-vaccination statements, and other unprofessional behaviours. Our profession’s reputation among other health professions is poor when compared with other allied health professions, and we need to address this. Here is a summary of A/Prof Walker’s ten point plan to help progress and advance the chiropractic profession into and beyond the 21st century. To ensure not only its survival, but its prosperity. For the benefit of not only those that practice chiropractic, but for those who will seek our service. 1. Improve education. This should be done at public universities with intellectual rigour. These institutions and the chiropractic schools within them should be research active. Education should require hospital rounds so that graduates can be exposed to people with real illnesses which can inform their clinical decision making. As well as this, hospital rounds will expose graduates to other professions and improve their ability to work as part of an interdisciplinary team.

2. Establish a progressive identity. Become world experts on spinal and musculoskeletal pain. Not an alternative system with a “funny belief”. 3. Develop a special interest for the profession. As a profession, we need something that sets us apart as experts in a distinctive area, whether that be refinement of evidence-based practice for spinal pain, or improved posture through enhanced muscle control. 4. Marginalise the extremists. We must question deviant ideas. Silence on these matters is not only consent, it is endorsement. It is not high treason to question rubbish and ridiculous ideas. If we do not do this ourselves, then we run the risk of all being tarred with the same brush. 5. Be PRO-public health. In every way. This includes childhood immunisation, smoking cessation programs, diet and nutrition, improving physical activity, lowering alcohol consumption, reducing the obesity burden and reducing the lower back pain burden to name a few. 6. Support the legitimate profession. Support those who engage in raising professional standards, improving clinical practice and growing research. Be wary of those with a newfound interest in evidence-based practice and examine t heir understanding of the concept. 7. Improve clinical practice. Homogeneity is not to be frightened of. Embrace evidence. Be willing to incorporate the latest evidence into clinical practice. Undertake sound, scientific professional development to improve clinical practice, not the latest practice building seminar.

8. Embrace evidence-based practice. Evidence-based practice does not include practitioner values or ideology. It is all about the patient in front of you. In the past, people have said “we know it works”. This is practice based evidence. “The practicemanagement guru told me it works.” This is eminence-based practice. It is important to be able to tell the difference between those examples and evidence-based practice. 9. Support Research. Research needs to become the number one aspiration of the profession. Without it, we won’t progress. We will stagnate. We need to support the training of career chiropractic researchers. The attitude in some circles that chiropractic researchers “couldn’t cut it in private practice” needs to be dispensed with. These are the people ensuring the progress of the profession. If we ignore research, the profession will wither on the vine. 10. Show Personal Leadership. Be a mentor to other chiropractors. Be a mentor to chiropractic students. Put the interests of the profession as a whole above your personal aspirations. And don’t expect someone else to do this for you. Take ownership of being a leader yourself. I can only endorse A/Prof Walker’s words. In 2011 John Reggars wrote the article in C&MT “Chiropractic at the crossroads or are we just going around in circles?” It would seem we have travelled around in another circle and have arrived at the crossroads again. Make no mistake, we may not have the luxury of travelling in another circle before we decide to take a path to ensure the profession’s long-term survival.

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Electronic Health Records and the Future of Chiropractic By: Melissa Wassell BSc(Chiro)/B.AppSci, AdvDipOHS,

Certified Health Informatician Australiasia (CHIA) The current health climate has created the ideal environment for a surge in the adoption of digital technologies with almost every industry being transformed by technology in some way. Amid this change, chiropractic is in a battle for digital relevance. I propose that other health professionals are leaving us behind when it comes to technology adoption. We need to collect our patient data in such a way that we can use it to our advantage, to create evidence and achieve great clinical outcomes. On the other side of healthcare, big data and artificial intelligence technologies are commonplace in hospital systems. This means that whilst chiropractic might be lagging now, we have a fantastic opportunity to learn from the health systems that are more technologically advanced which will help to propel our profession forwards. All practitioners want to practice evidence-based medicine. Once data is available, we can create evidence, and practitioners can expand their advertising to increase market share. Furthermore, we all want our patients to have a fantastic experience in the clinic and to share that experience with peers. The best way to do this is to get positive clinical outcomes and to create certainty in communications to patients. The good news is that we can do all of this! We just need to be more effective in using the data that is collected in practice to help us make smarter decisions. Electronic Health Records (EHRs) were mandated in the US for all healthcare in 2014, while meaningful data is collected and exchanged within many European countries. Sweden has the vision to be the best in the world in making use of health digitisation and e-health initiatives. In some states of Australia, hospitals have 100% adoption of EHRs while GP clinics are around 50%. As physiotherapists work in hospital settings, they already have access to large EHR systems to collect clinical data. Allied health lags behind however, with systems that are mostly content management, collecting free-text data that is unhelpful in creating meaningful information to assist clinicians to make informed decisions. When patient data is recorded electronically in a standardised way, it makes it far easier to conduct research. Studies done with EHR data don’t have the expensive recruitment costs, limited sample sizes and long timeframes for completion. EHR based studies usually have much larger populations of patients that can be studied in a real-world setting which allows us to understand how our patients respond in real life, rather than limiting the study to a particular intervention in a healthy adult population. Good quality clinical data allows efficient analysis so clinical outcomes to different clinical conditions and body regions, pain levels and disability measures can be tracked. Practitioners will be able to see how effective they are at determining prognosis and the length of care required. Analysis of outcomes to MSK and non-MSK conditions will be possible, as long as data is captured in a meaningful way. EHR data provides the opportunity to assist in creating a gold standard of care and allow for benchmarking against our peers. Consider how constant feedback on our outcomes could help train our new practitioners and keep us continuously improving our patient outcomes throughout our careers. This is possible utilizing well-structured EHRs with drop-down lists and option buttons for each piece of data we capture. The next step, once we collect quality clinical data, create evidence and analyse our outcomes, is to use the data to develop predictive models. Predicting health outcomes isn’t new, and even in chiroprac-



tic there is some evidence around predicting outcomes to care. However, because EHRs can provide more data on an individual, machine learning models can utilise all that data to make specific recommendations which are personalised to the patient in front of us. Machine learning has significantly contributed to personalised medicine with many ICUs and emergency wards now having predictive models built into their clinical workflows. These models provide clinicians with alerts or risk predictions in real-time, as the clinician enters data into the system. Clinicians will be able to consider the predictions as part of their clinical decision-making process. There are machine learning models that predict cancer from imaging, that match patients to doctors specialising in their area, that detect disease and risk of poor surgical outcomes, or risk of readmission to hospital. When it comes to reading imaging, some models outperform the human ability to detect disease. Clinicians will become experts at data analytics, analysing health data inputs from many sources. Machine learning models will become our clinical assistants. Machine learning doesn’t suffer from the same biases that humans do, and they are not forgetful. A machine learning model for a clinic might look at 80-100 pieces of data about the patient in front of us, weight and combine them, to create a prediction on the likelihood of a successful outcome, or the number of visits that patient will need. Our brains can’t connect all the variables that contribute to an accurate prediction on their own. Artificial intelligence and machine learning models will make for a high degree of certainty when discussing a report of findings with patients. While this discussion has been quite optimistic and future-focused, it is good to know that there are organisations that are working toward this goal. Work Healthy Australia has developed a well-structured EHR, which captures over 150 points of data with each care plan. With over 100,000 patient care plans in the EHR, we are experimenting with machine learning to determine predictors for outcomes to care. The models may help improve the clinical skills of the clinicians working on the system and improve patient outcomes. There are many challenges ahead to get to where we need to be, but we are on the way. At CQU, our team of Andrew Vitiello, Henry Pollard, Pavle Jeric and myself will be using the Work Healthy Australia EHR data to hopefully produce some new research for the profession. We intend to determine whether the quality of data in the system can be used for outcome predictors, and then determine which fields are predictors of the outcome using machine learning. For our profession to move forward as primary care practitioners we need to change and consider EHRs now. This adventure begins with electronically capturing good quality clinical data about the patient, and the injury, and from the work history details, examination findings, and patient outcomes (PROMS). Our choices will lead our clinics and the profession forward, to rapidly improve our research capacity and in turn, this will lead to more evidence that allows us to document a broader range of reliable clinical outcomes. We can then use this to promote the profession and advertise our achievements more widely to gain greater market share. Collectively, this evolution in data collection, handling and use will allow the training of future practitioners with remarkable clinical outcomes and that can only be good for our patients and our profession.


The new Registration Standard: CPD Step 1 - Self-Assessment By: Rod Bonello BSc(Syd), DO, DC(SCC), MHA(UNSW), FRCC

Authors note: This article draws heavily from the guidelines and explanatory resources of the Chiropractic Board of Australia (CBA) on Continuing Professional Development (CPD), as well as research in the field of health professional education. However, all statements are Professor Bonello’s interpretations and opinions on this issue. He recommends that all chiropractors make themselves fully conversant with the CBA guidelines and support resources in seeking to derive maximum benefit from the new system as well as ensure they remain fully compliant with the regulations.

The CPD cycle is depicted below.

The CPD Cycle

On 1st December 2019 the new Registration Standard: CPD came into effect. The guidelines applying to this standard can be found at

The issue In several countries continuing professional education has moved from counting the hours undertaken in formal and informal learning activities to a system that explicitly links guided development to change in practice. [Dornan 2008] It is important to note that under CBA’s new Registration Standard: CPD the face-to-face hours that you spend attending a seminar or the time it takes you to participate in another learning activity may not all count toward your CPD requirements under this new system. The CBA have clarified that for a learning activity to count as CPD it should: • seek to improve patient outcomes, safety and experiences • draw on the best available evidence, including well established and accepted knowledge that is supported by research where possible, to inform good practice and decision-making • contribute directly to improving your competence (performance and behaviour) and keeping you up to date in your chosen scope and setting of practice • build on your existing knowledge It is the responsibility of members of a health profession to be accountable to their patients and to the community. They are expected to develop and maintain the knowledge base and technical skills to competently care for patients. They must also uphold the ethical standards defined in the Code of Conduct in the service of patients, colleagues and indeed, the profession. Continuing Professional Development addresses these responsibilities. A vital component of the new standard is the importance of self-assessment in the CPD process. With the unrelenting expansion of knowledge and technology in the health care field there is an increased expectation that clinicians be able to evaluate their own deficiencies and needs. In fact, self-assessment is the first step in the CPD cycle and is probably the most critical component.

Reference: Guidelines on continuing professional development (CPD) CBA 2019

Fundamentally, this first step is vital. So much so in fact, that in this issue of CA News we will only be discussing this first step. Reflecting on your practice to determine what it is that you need to learn is the key activity and requires an honest appraisal by the practitioner so as to identify their current strengths and weaknesses. If not undertaken properly, the planning and conduct of CPD in all likelihood will be poorly focused, misguided and of limited value. Why is this? Because the first step involves the identification of learning needs.

The challenges At this point, two kinds of error may arise. In the first instance a genuine need may not be realised by the practitioner and an important area neglected. An example would be where a practitioner is unaware of (or has forgotten) the difference between intermittent vascular claudication and neurogenic claudication in back and leg pain patients. Understanding the different aetiologies of the two conditions and their different management is essential in the competent management of patients with these conditions. Therefore, in terms of planning CPD, being unaware of the clinical difference, such a practitioner would not even realise that he or she was lacking in this area and therefore would not be able to identify this as an area of learning need. That area of ignorance would be ongoing. Simply put, you don’t know what you don’t know.

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Secondly, a practitioner may falsely believe that revising a topic that they have already mastered is a valuable learning experience. A common example would be where a practitioner identifies with a named technique group and spends the vast majority of further education time and effort in attending meetings of that technique group. The repeated reinforcement of dogma in diagnostic approach or technique application in this example does not represent real learning and is certainly not an agent for growth, development and change. These two types of error are common, and both are related to a lack of appreciation of the diversity of topics available and their relative merits and may be reflective of siloed thinking. Many papers have acknowledged that self‐assessment, as a skill, is necessary for competent practice, going so far as to say that it is a prerequisite for the effective clinician. Yet, the literature as a whole has formed the consensus position that individuals can not accurately evaluate their own performance. [Redwood et al 2010]. Professor Eva (2004) in reviewing various health professions agrees, having reported - “A ubiquitous finding in the study of self-assessment, however, is that self-ratings are poorly correlated with other performance measures.” Let us go back to the concept of change. Effective CPD has been linked to change. In fact, I would argue that unless a CPD activity has created at least a small change in the learner, then its value is questionable. Simple reinforcement is not enough. Following the learning activity, the chiropractor should be able to reflect that the knowledge, understanding or behaviour is now either better, more efficient, more effective, or undertaken with more confidence than before the activity.

Potential solutions Much of the foregoing has focused on challenges and the difficulties inherent with the first step of the CPD cycle. But that is not to say that the process is flawed or weak. When practitioners get it right there is the valuable pay-off of well-targeted, enhanced learning that addresses the specific needs of the individual practitioner and best serves the needs of patients. It also should minimise the cost of chasing multiple expensive programs that add little to the real needs of practitioners. The following suggestions can help chiropractors identify their learning needs.

Where a better understanding of a topic or mastery is sought: 1. Refer to published consensus statements on diagnosis, treatment and management. Identify recommendations that you currently do not follow or procedures that you do not use and consider whether taking these on may be appropriate to your needs. 2. Find other well‐defined external standards such as those promulgated by reputable specialist or special interest groups. When chiropractors are asked to comply with new standards: 1. Refer to the standards authority for guidance. 2. Seek guidance from Chiropractic Australia. 3. Consult with staff from one of the universities that teach chiropractic. Where a chiropractor is advanced in a particular area and is seeking a higher level of mastery (eg sports chiropractic). 1. Dornan suggests that the learners themselves should be able to define their personal goals. 2. Seek the advice of colleagues who have that level of mastery. Where areas of difficulty are encountered (eg a serious iatrogenesis): 1. Seek external assessment from peers, or better still, from known experts. 2. Perform a critical incident analysis with the input from self‐ assessment.” Once learning needs are properly identified, following through with targeted CPD activities and recording progress are the next and substantially easier steps. At Chiropractic Australia we recognize the changes required by the revised Registration Standard bring new challenges to members as they learn how to manage their CPD. To assist members with this we have developed a CPD platform to log your learning goals and track your activity during the CPD cycle. The platform allows members to record and store activities undertaken along with proof of completion for verification and auditing purposes. As this is the first CPD cycle under these revised guidelines many clinicians are likely to be unfamiliar with the process. However, there is little doubt that we will all develop greater comfort with the process over time.

References: Dornan, T. (2008), Self‐assessment in CPD: Lessons from the UK undergraduate and postgraduate education domains. J. Contin. Educ. Health Prof., 28: 32-37. doi:10.1002/chp.153 Redwood, C., Winning, T. and Townsend, G. (2010), The missing link: self‐assessment and continuing professional development. Australian Dental Journal, 55: 15-19. doi:10.1111/j.1834-7819.2009.01177.x Eva KW, Cunnington JP, Reiter HI, Keane DR, Norman GR. How can I know what I don’t know? Poor self- assessment in a well-defined domain. Adv Health Sci Educ Theory Pract. 2004;9(3):211-224. doi:10.1023/B:AHSE.0000038209.65714.d4




SpineOnline 2020 Review By: Michael Swain and Scott Charlton

The COVID-19 pandemic has caused unprecedented challenges for Australian chiropractors and the community at large. In March, the CEOs of Chiropractic Australia (CA) and the Australian Chiropractors’ Association (ACA) made the difficult decision to withdraw from the planned chiropractic program for SpineWeek 2020 after 2 years of developing the joint-venture initiative. In an effort to provide value to their members, the two organisations began a collaborative effort to repurpose the chiropractic stream from the original SpineWeek program into an association led virtual conference, SpineOnline 2020. The CA-ACA SpineOnline 2020 conference aimed to support and guide Australian chiropractors during this testing time. The educational program offered members the opportunity to learn from local and world-leading chiropractors, and international experts in the spine field. The week-long event was opened on Monday 15th June by the association’s presidents, Professor Rod Bonello and Dr Anthony Coxon. The session that immediately followed the opening established the format for each daily session which consisted of a prerecorded presentation followed by a live Q&A with the presenters, with each session lasting approximately 2 hours. Monday’s session was dedicated to the process of translating knowledge from research evidence into clinical practice. Professors Simon French and Jan Hartvigsen and Dr Hazel Jenkins provided an overview of knowledge translation and illustrated examples relevant to chiropractic practice. The Tuesday session was dedicated to best practice and Associate Professor Michael Schneider and Professors Rachelle Buchbinder and Chris Maher presented on contemporary models of spine care and pertinent clinical messages reported in the recent Lancet series on back pain. On Wednesday Dr Matthew Fernandez, Dr Diana De Carvalho, Dr Katie de Luca and Associate Professor Manuela Ferreira presented on physical activity and geriatrics and explained how to impart important physical behaviour advice and care for older people. Paediatrics was the topic for Thursday’s session with Dr Katie Pohlman, Dr Mike Swain and Dr Anthony Coxon providing an evidence-based overview of the field and discussing contemporary issues facing Australian chiropractors. The Friday session was dedicated to patient management and innovation and Dr Aron Downie and Dr Andreas Eklund reported on new evidence to support clinical approaches and maintenance care while Dr Melinda Wassell, Dr Martha Funabashi and Dr Arnold Wong gave engaging TED style talks that drew attention to emerging technologies for conservative spine care.

Saturday was the last day of the conference and was dedicated to biomechanics. Emeritus Professor Nik Bogduk and Professor Greg Kawchuk provided thought provoking presentations on establishing the source of spinal pain, and the role of big data in the future of chiropractic. The conference was closed by CA CEO Ms Tina Rankovic and ACA CEO Dr Matthew Fisher. Our gratitude and appreciation go to all the speakers for giving such high-quality video presentations and for sharing their expert insights during the live discussion panel broadcasts. Our thanks to the CARL Fellow moderators, Drs David McNaughton, Sasha Aspinall and Craig Moore. SpineOnline 2020 was truly a team effort. The Organising Committee established some 2 years ago for SpineWeek included Dr Michael Swain and Dr Peter Werth both from CA and Ms Glynis Grace and Dr Scott Charlton from ACA. In addition, there was much hard work occurring behind the scenes with professional staff including and Stephen Kynoch (CA), Ariel Tate (ACA) and Debbie Kelly (ACA) helping to make this event a success. We hope that this initiative provided our chiropractic community with an engaging and uplifting professional development resource. We wish everyone well as chiropractic practices adapt to the current challenges and strive for future success.

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Marketing your small business in a pandemic world There was once a time when advertising a business meant elaborate advertisements on TV or large colourful newspaper spreads. Fastforward to 2020, not only is the marketing landscape completely transformed, but a global pandemic and resulting economic crisis has forced businesses, large and small, to pivot their marketing (and fundamental operations) in a way most could not have imagined. The challenges presented by COVID-19 has also brought opportunity, the chance for businesses to start fresh, reflect on what they’ve been doing, and make the necessary investments if they are in a position to do so. Here are three lessons small business owners may take from the COVID-19 economic climate, as well as some steps you can take now to future proof your business as we (hopefully) enter the postpandemic world.

The importance of having a digital presence

online bookings and replace client face to face meetings for zoom calls. Regardless, if you are a big corporation or a small family owned business, this pandemic has created a level playing field which is why it is critical to utilise this time as best as possible.”

Social Media – remaining visible As staying home became the norm, social media usage saw a huge spike as people tried to stay connected with loved ones and maintain a sense of normal. It is possible that even those who previously had not used social media have now started to do so. If you don’t already have a social media account for your small business, the fallout from the pandemic should hopefully be enough to convince you to open one. Social media can help your business build up presence and awareness and allow your loyal clients to advocate your business to friends and family. If your business is new to social media, here are some tips to help you get started: Firstly, decide which social media platforms will be relevant to your business by studying your client base. There is no need to have an account on every single platform, rather focus your advertising efforts on the platforms where you feel you will get the most reach. COVID-19 has also changed social media habits of consumers, with some platforms seeing an increase, and some platforms seeing a fundamental shift in the way they are used, so make sure to do your research before jumping in.

What quickly became clear when many businesses were forced to shut their storefronts was that those with a digital presence had an advantage, with some online retailers reporting huge increases in sales.

Secondly, consider whether your business will benefit from paid advertising on the social media platform you choose. Paid advertising can be a very cost-effective way to reach large numbers of customers (and target the right ones).

A website and digital presence will be an advantage to your small business regardless of whether there are lockdowns in place, and regardless of whether you can service clients online or not, as it can enable you to maintain a connection with your clients even when they are not buying from you. An online presence will help to ensure your business name stays front of mind.

Another option you could consider is social media activity with purpose. This is where you align your business with a charity or activity that benefits your local community. A growing number of companies are adding a live donations function to their social media presence which may be an indication that users of social media want to feel like they are contributing to a purpose. While many large corporates have been able to make donations on a scale comparable to their size, this may not be possible for small businesses struggling with cash flow issues. Instead, the opportunity may exist for small business owners to engage and enable customers to participate in their giving efforts as demonstrated by this small business, Real Peas café.

For example, here’s how Designer Plants, an artificial plant wholesaler used their website to add value and remain relevant to their customers: “Our observation was that consumers, particularly in Australia, have taken it upon themselves to spend their extra time by getting busy in their home on their improvement projects. After seeing a greater shift to online sales, compared to visits to our showroom, we reviewed all of our marketing messages and put greater emphasis on DIY messages. This has proven to be very effective for us. We were expecting to see falls during this challenging time period however, with quick decision making, we have been able to counteract this.” Ray Pastoors, Designer Plants® Digital Marketing Manager. And since lockdown measures have given small business owners the very rare gift of free time, some have used this time wisely to develop their website, and invest in their overall digital presence, such as photographer Peter Petinos, owner of Anello Weddings and Peter in Photography: “…this free time has allowed my marketing to excel more than ever...I have had the chance to develop new websites, create



Real Peas, a café and gourmet foods provider based in the heart of Sydney, regularly donated food leftovers to charities pre-lockdown. However, since the temporary closure of their stores, the amount of food they could donate reduced significantly, so the café owner took to social media to encourage donation - for every home delivered meal, and use of their hashtag, they donated a meal to the charity. The campaign has proven highly successful, not only as a charitable activity but also for Real Peas long-term branding.

Email – keeping in touch Just like having a website, email marketing of your business will also help you stay on your clients’ minds even when they are not buying from you. The last few months has demonstrated the importance of this channel as a means to communicate operational information to clients. For example, many businesses used this channel to communicate important information such as modified trading hours, changes in business procedures, as well as reassuring customers of the measures taken to ensure health and safety of consumers, such


as cleaning routines and social distancing within premises. Some brands added a human touch by addressing employment impacts on their staff and being transparent with customers about how their staff members were being supported.

bers and our number of clients continue to grow. If you’d like to find out more about Aon or get a quote, please visit, call 1800 805 191 or email

The importance of empathy

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Whether you already have an online presence or are still in the initial stages of establishing one, one of the most important things to keep in mind when communicating during uncertain times is empathy. Sometimes weaving too much relevance into your communications can be seen as opportunistic. This crisis has forced many businesses to think critically about their marketing and identify messages that are truly valuable to their audience. However, this lesson should not be exclusive to the COVID-19 environment and should be an important one to take on board moving into the future.

The views expressed are those of the interviewee only and do not necessarily reflect those of Aon. Aon has taken care in the production of this document and the information contained in it has been obtained from sources that Aon believes to be reliable. Aon however does not make any representation as to the accuracy of the information received from third parties, nor its suitability of fitness for any purpose. This information is intended to provide general information only. It is not intended to be comprehensive, nor does it, or should it (under any circumstances) be construed as constituting legal advice. You should seek independent legal or other professional advice before acting or

About the author Aon is a leader in risk and insurance and provides a range of insurance solutions for chiropractors. As the preferred insurance broker to Chiropractic Australia, Aon is proud to provide cover for CA mem-

relying on any of the content of this information. Aon will not be responsible for any loss, damage, cost or expense you or anyone else incurs in reliance on or user of any information contained in this document.


A Very Special, Once Only, Member Only, CPD Offer The end of the 2019-20 CPD year is fast approaching. If you are yet to complete your required minimum of 20 hours of CPD activity for the year, CA has a very special offer to assist you.

Terms and conditions

Purchase any two or more of our online programs from those on offer at (excluding the Risk Management modules) and receive a 50% credit on the cost the cheapest program, once you have completed it.

• The 50% discount applies to the cheapest program you purchase in any single transaction where you purchase two or more programs.

This is a win-win offer. You accrue CPD hours and you get one program at an even lower cost than the already discounted member price. To receive your additional 50% discount, forward a copy of the Certificate of Completion for the cheapest of the programs you have selected to Kristine Riekstins in the CA office. Your 50% discount will be credited to the debit or credit card you used to purchase the program.

• This offer applies to programs purchased and completed prior to 30th November 2020.

• Proof of completion is the Certificate of Completion which is downloadable once you have successfully completed the program. Certificates can be sent to Kristine Riekstins at the CA office Suite 2 / 1 Rooks Road, Nunawading Vic 3131 or by email to • This offer excludes any of the Risk Management modules, the member-only CA CPD Package or any of the programs available via a subscription to GEN-C.

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Implementation of a novel clinical PAthway of CarE for common musculoskeletal disorders in primary care (PACE MSK Study) The pathway will be implemented in an Australian-wide NHMRC-funded trial, involving researchers and clinical experts across low back pain, neck pain, whiplash and knee osteoarthritis. More than 1000 patients with musculoskeletal disorders will be recruited. We are hoping for a strong involvement from Chiropractic Australia chiropractors as primary health care practitioners.

Drs Katie de Luca and Matthew Fernandez discuss their involvement in the NHMRC funded ‘Innovative solutions and clinical pathways to improve management of common musculoskeletal disorders’.

Will you step up and be involved? We need help from chiropractors to recruit patients who will be stratified on prognosis and who may or may not receive specialist care. Patients with a good prognosis, will remain under the care of the chiropractor while patients with a poor prognosis will received additional support specialist care alongside their chiropractic care. Payment is available for the recruitment of patients from clinical practice.

Musculoskeletal (MSK) pain disorders such as low back pain, neck pain, whiplash and osteoarthritis are Australia’s highest disease burden. Possible reasons for this include clinical guidelines being poorly implemented in primary healthcare, increasing burden on the healthcare system (eg, overloading GP/primary care system) or the difficulty of identifying patients at medium-high risk of poor recovery.

Contact or for more details.

In Australia, many people with whiplash receive treatments not supported by clinical guidelines and more than 50 per cent of people receive unnecessary imaging. Appropriate advice on strategies to manage low back pain is provided in only 21 per cent of GP consultations. Despite the unanimous recommendation for active therapies such as exercise, only 13 per cent of patients with knee osteoarthritis receive such advice. Chiropractors play an integral role in the clinical pathway for managing common musculoskeletal disorders and should be involved in innovative solutions to reduce the burden of musculoskeletal pain.

How does this pathway differ from normal practice? When a person with a musculoskeletal problem is not responding, or has a complicated presentation, their care pathway often leads from the primary healthcare practitioner to a surgeon. However, the vast majority of musculoskeletal complaints do not require surgery. The care pathway we are implementing facilitates access to expert non-surgical care with specialist musculoskeletal practitioners.

Often, patients with a good prognosis (low risk) recover well with minimal care, guideline-based advice and exercise provided by chiropractors and physiotherapists. To assist in management of low risk patients, clinicians and patients will have access to the My Pain Hub website – a one-stop portal for up-to-date and evidence-informed resources regarding low back pain, neck pain/whiplash and knee osteoarthritis. However, we are interested in providing patients at risk of not recovering well the right care. These patients will be referred to a specialist musculoskeletal therapist who will undertake further examination of domains that may be related to delayed recovery or higher levels of impairment. The specialist will liaise with the chiropractor on further care that is targeted and patient-centred. On occasions where the patient has a more complex presentation, the musculoskeletal specialist may manage the patient for a few sessions before referring the patient back to the primary chiropractor. Alternatively, the specialist may refer the patient for an opinion from another health or medical practitioner if appropriate (eg, psychology, pain physician, orthopaedic or neurosurgeon, rheumatologist). This pathway, in the chiropractic setting, has yet to be formally tested so consequently, we are looking for chiropractors who are interested in engaging in this clinical pathway to contact us!



Will you still treat your patient? Patients with a good prognosis, will remain under the care of the chiropractor while patients with a poor prognosis will received additional support specialist care alongside their chiropractic care.

RESEARCH NEWS What are the benefits of this pathway for chiropractors? Chiropractors enjoy working with one another to do the best they can for their patients. Referring a patient with a more complicated presentation to a recognised expert in that area or condition, will offer the referring chiropractor a second opinion, or a ‘sounding board’. From the MSK specialist’s perspective, having the opportunity to collaborate with chiropractors to help their more complex patients can bring a great sense of professional satisfaction. Take home message for Chiropractic Australia chiropractors: Our profession plays an integral role in primary health care. This is the first research opportunity for chiropractors to participate in supportive, collaborative clinical pathways that involve physiotherapists, specialists and the treating chiropractor. For patients: 1. Patients are randomised to different clinical care pathways that aim to improve health care delivery and may receive individualised care according to need. 2. Patients will complete a baseline questionnaire, and follow-up questionnaires at 3, 6 and 12 months after randomisation. 3. They will receive usual care from their chiropractor or the PACE – MSK innovative clinical pathway

Why get involved? • You are paid $100 for each patient successfully enrolled. • You remain the primary health care professional for your patient and maintain engagement. You don’t lose contact with your patient. • You have an opportunity to be involved in a NHMRC funded study that aims to improve care pathways for people with musculoskeletal disorders. • You have an opportunity to collaborate with specialist clinicians with additional expertise in complex musculoskeletal conditions. • We can provide in-service professional education to you and your staff.

For chiropractors: 1. Identify patients who have sought care within the last four weeks who have neck pain OR non-specific low back pain OR knee osteoarthritis. 2. If interested, send participant contact details to PACE – MSK staff 3. Get paid $100 for each patient successfully enrolled.

RESEARCH FOUNDATION Interested in completing a PhD? Chiropractic Australia Research Foundation is calling for applications for funding of a PhD Scholarship A call for Chiropractic Australia (CA) Research Foundation PhD Scholarship applications is open for scholarships commencing 2021 for three years full time, or six years part time. The scholarship will provide the successful recipient with a stipend of $30,356 per annum, plus a research support package of $2,000 per annum for consumables and travel. The scholarship will be paid at 50% of this rate for a part-time candidature. This year, CA Research Foundation is pleased to announce a PhD Scholarship to be named after Professor Bruce Walker, AM, titled “Walker Chiropractic Australia Research Foundation PhD Scholarship”. This scholarship will be awarded to the highest ranked applicant each year when their PhD proposal is in the area of Prof Walker’s research. This scholarship brings some additional funding in the form of support to attend Chiropractic Australia’s Research Day each year of the PhD. More information is available in the application guidelines. For more information go to: Applications for PhD Scholarships close on Saturday 31st October 2020 at 5pm Australian Eastern Daylight Saving Time.

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Chiropractic COVID-19 Global Impact Survey Get ready to participate!

Members of Chiropractic Australia will soon be invited to participate in an international survey of chiropractors being conducted across 5 continents, including Australia, Canada, Denmark, Hong Kong (China), Sweden, United Kingdom (UK) and the United States (US).

Coronavirus (COVID-19) is a highly transmissible disease with approximately 30 million confirmed cases and 1 million related deaths worldwide. While Australian chiropractors have been essential healthcare workers addressing neuromusculoskeletal disorders during this time, the impact and response to the pandemic by Australian chiropractors is under researched.

With over 100,000 practising chiropractors worldwide, this is the first international-based study that seeks to provide important insights into the impacts and changes to the healthcare delivered by chiropractors during COVID19. Your participation will give you the chance to share your own experience and contribute new knowledge about the personal and professional impact of this historic pandemic. This research project is being conducted by a large international team of chiropractic researchers including researchers from Australia. Findings from this study may contribute vital knowledge that is needed to help inform public health procedures within chiropractic settings that may benefit both you and your community.

You will soon receive an email with a link to the online survey via Chiropractic Australia who supports practitioner participation in this study. If you are interested in more information, please send an email to the study chief investigator, Dr Craig Moore at

Thank you in advance for your valued participation in this important upcoming Global COVID-19 study.




Best Article – C&MT 2nd Quarter 2020 THE NORDIC MAINTENANCE CARE PROGRAM: MAINTENANCE CARE REDUCES THE NUMBER OF DAYS WITH PAIN IN ACUTE EPISODES AND INCREASES THE LENGTH OF PAIN FREE PERIODS FOR DYSFUNCTIONAL PATIENTS WITH RECURRENT AND PERSISTENT LOW BACK PAIN - A SECONDARY ANALYSIS OF A PRAGMATIC RANDOMIZED CONTROLLED TRIAL Andreas Eklund, Jan Hagberg, Irene Jensen, Charlotte Leboeuf-Yde, Alice Kongsted, Peter Lövgren, Mattias Jonsson, Jakob PetersenKlingberg, Christian Calvert & Iben Axén. Chiropractic & Manual Therapies 2020 28:19 As previously reported, patients with recurrent and persistent low back pain (LBP) reported significantly fewer days of bothersome pain when receiving care regardless of symptoms,

Abstracts WHAT PREDICTS THE FREQUENCY OF CHIROPRACTIC CARE? In view of the observation that for chronic low-back pain (CLBP) and chronic neck pain (CNP), several provider-based nonpharmacologic therapies have now been recommended, researchers here sought to provide one glimpse into the long-term use of nonpharmacologic provider-based care via determining the predictors of visit frequency in a large sample of patients with CLBP and CNP using ongoing chiropractic care. From a large national sample of chiropractic patients in the US with non-specific CLBP and CNP (852 patients with CLBP and 705 with CNP), collection of observations data was performed. Among these patients, they observed average visit frequency of 2.3 chiropractic visits per month—ie, just over one visit every two weeks. Significant variation in this visit frequency was observed by the characteristics of the patients, the characteristics of the treating chiropractors, and the state in which care was given. In the final models, those with CLBP and some coverage for chiropractic showed increased visit frequency (0.44 visits per month), but coverage was observed to have little effect on visits for patients with CNP. Further, more visits were reported for patients with worse function or just starting care and fewer visits

maintenance care (MC), compared to receiving care only when a relapse occurred. This was true mainly for patients with a “dysfunctional” psychological profile, described as having high pain severity, marked interference with everyday life, high affective distress, low perception of life control and low activity levels. In this secondary analysis, we explored wherein this effect lay by examining pain trajectories around a treatment visit. Clinically, patients experience more pain leading up to the visit, and then pain relief thereafter. Patients reported their “number of days with bothersome pain” weekly with text messages, and the participating chiropractors reported the date of each treatment. A treatment period was defined as treatment(s) with at least 4 weeks since the previous treatment. The pain trajectory was examined 3 weeks before and 3 weeks after the initial visit in a new treatment period.

were reported for those near to ending care. Patients with higher visit frequency were reported for chiropractors who reported seeing more patients per day, and fewer visits per month were reported for the patients of chiropractors with 20 to 30 years of experience. In addition, the state in which care was received made a difference, likely through state-level policies and regulations, after controlling for both patient and chiropractor characteristics. Herman et al. Predictors of visit frequency for patients using ongoing chiropractic care for chronic low back and chronic neck pain; Analysis of observational data. BMC Musculoskeletal Disorders. May 18, 2020 PREDICTORS OF LOW BACK DISABILITY IN CHIROPRACTIC AND PHYSICAL THERAPY SETTINGS. This study sought to determine predictors of disability at 6 month follow-up in patients with LBP at medium risk of ongoing disability. Baseline data was collected from 108 patients with medium-risk chronic non-specific LBP (mean age 50.4 years, SD 13.6) from six private chiropractic and physiotherapy clinics in Australia who took part in a randomised control trial. All patients received a pragmatic course of multimodal physical treatments [e.g., manual therapy (spinal manipulation or mobilization and/or soft tissue massage)] combined with advice, education and exer-

We found that the MC patients with a dysfunctional profile reported a significantly “flatter” pain trajectory, they did not experience as much pain in the pain relapse. In addition, these patients also reported longer pain-free periods, i.e. longer time between relapses, compared to the control group. This amounted to nearly 10 pain-free weeks for the one-year duration of the trial. What can we learn from this? It is clear that MC is highly effective for a certain psychological group of patients with recurrent and persistent LBP, the dysfunctional group. It is also clear that the effect of fewer “days with bothersome pain” is achieved by “flattening” the pain curve as well as extending the time between relapses. Full article: https://chiromt.biomedcentral. com/articles/10.1186/s12998-020-00309-6

cise. Baseline prognostic variables included sociodemographic, physical and psychological characteristics. Primary outcome was disability (Roland Morris Disability) at 6 month follow-up. Multivariable linear regression analysis was conducted. This study found that the variables remaining in the final multivariable model: lower work ability (β = − 1.05, 95% CI − 1.40 to − 0.70; p < 0.0001) and consultation with a medical specialist for back pain in the preceding 3 months (β = 3.35, 95% CI 1.14 to 5.55; p < 0.003), which significantly predicted higher disability at 6 months (unadjusted R 2 = 0.31). Those with a lower work ability (scale 1 to 10) and who had seen a medical specialist for their back pain were more likely to report greater LBP-related disability at 6 months. The authors concluded that patients with chronic LBP presenting to primary care with lower work ability and recent consultation with a medical specialist for LBP are more likely to have a worse prognosis; these are indicators to clinicians that standard conservative care may not adequately manage the patients’ needs. Petrozzi, et al., Predictors of low back disability in chiropractic and physical therapy settings. Chiropractic & Manual Therapies Vol 28: 41, 2020

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Systematic Reviews EFFECTIVENESS OF ELASTIC TAPING FOR KNEE OA. The aim of the study was to assess the effects of elastic taping on pain, physical function, range of motion, and muscle strength in patients with knee osteoarthritis. Eleven RCTs involving 490 patients with knee OA were included. A statistically significant difference was detected in pain (standardized mean difference = −0.78, P < 0.00001), physical function (standardized mean difference = 0.73, P < 0.00001), range of motion (mean difference = 2.04, P = 0.04), and quadriceps muscle strength (mean difference = 2.42, P = 0.0004). No significant differences were found for the hamstring muscle strength. Ye, W et al., Effectiveness of Elastic Taping in Patients With Knee Osteoarthritis. A Systematic Review and Meta-Analysis. 2020. American Journal of Physical Medicine & Rehabilitation PNEUMOCOCCAL VACCINATION REDUCES ACUTE ADVERSE CARDIOVASCULAR DISEASE IN ADULTS Via this meta-analysis, researchers studied the effect of PPV23 (23-valent polysaccharide pneumococcal vaccination) on cardiovascular disease. They explored Embase, Medline and Cochrane to identify all studies assessing PPV23 vs a control (placebo, no vaccine or another vaccine) for any cardiovascular events including myocardial infarction (MI), heart failure, cerebrovascular events. They analysed 18 studies with 716,108 participants. Findings revealed that PPV23 brought about reduction in the risk for some adverse cardiovascular

events, particularly acute MI in the vaccinated population, especially for those people aged 65 years and older. Based on the findings, experts suggested that vaccinating the group who is at greater risk for cardiovascular diseases would be a highly beneficial step. Marra, et al., The protective effect of pneumococcal vaccination on cardiovascular disease in adults: A systematic review and meta-analysis. International Journal of Infectious Diseases | July 30, 2020 CANCER AND MORTALITY RISKS OF PATIENTS WITH SCOLIOSIS FROM RADIATION EXPOSURE Researchers analysed data from cohort, case–control or cross-sectional studies, to determine the long-term health effect of cumulative radiation exposure from full-spine radiographs on children/adolescents with scoliosis. 9 studies combined for 35,641 subjects from 1912 to 1990 and found that when compared to controls, pooled incidence rates of cancer, breast cancer and cancer mortality of patients with scoliosis from repeated radiographs and pertaining cumulative radiation dose resulted in statistically significant higher rates [rate of cancer, odds risk (OR) = 1.46, p < 0.00001; breast cancer, OR = 1.20, p = 0.02; cancer mortality, OR = 1.50, p < 0.00001]. Applying low-radiation or radiation-free and efficient methods to monitor the evolution of children/adolescents with scoliosis was advised. Luan, et al., Cancer and mortality risks of patients with scoliosis from radiation exposure: A systematic review and metaanalysis. European Spine Journal | August 29, 2020

Info Bites POOR WORK ABILITY AND SLEEP DISTURBANCE AT RISK OF LONGTERM NP. Researchers conducted a cohort study based on three subsamples from the Stockholm Public Health Cohort to evaluate work ability with items from the Work Ability Index, perceived mental and/or physical work ability. This study’s findings demonstrated that workers with occasional neck/back pain NBP who have poor work ability and/or sleep disturbances are at risk of developing limiting NBP. Holm et al. Risk of transition from occasional neck/back pain to long-duration activity limiting neck/back pain. BMJ Open | June 6, 2020



YOUNGER THE AGE OF ONSET OF HYPERTENSION THE HIGHER THE RISK FOR CARDIOVASCULAR DISEASE Researchers undertook this prospective analysis to investigate the links of hypertension onset age with cardiovascular diseases (CVD) and all-cause mortality among 71,245 participants without hypertension and CVD in the first survey (July 2006 to October 2007) of the Kailuan study, a prospective cohort investigation in Tangshan, China. Experts randomly picked 1 control participant for each new-onset hypertensive participant, matching for age (±1 year) and gender. Overall 19,887 case-control pairs were included. Overall 1,672 incident CVD cases and 2,008 deaths were reported during an average follow-up of 6.5 years. Findings revealed a higher risk for CVD and all-cause mortality in relation to hypertension, and the links were identified to be stronger with a younger age of onset. Wang et al., Association of age of onset of hypertension with cardiovascular diseases and mortality. Journal of the American College of Cardiology | June 10, 2020. FORMAL PHYSIOTHERAPY AFTER HIP AND KNEE ARTHROPLASTY MAKES NO DIFFERENCE TO PATIENT OUTCOMES. In this study, the differences in costs and functional outcomes were compared in patients receiving formal PT and those who did not follow primary total hip (THA) and knee (TKA) arthroplasty. Researchers evaluated claims data from a single private insurer distinguishing patients who had undergone primary THA or TKA from 2015 to 2017 in our practice. They recorded demographics, comorbidities, number, and cost of PT visits in a 90-day episode of care. They conducted a multivariate analysis to distinguish significant predictors of outcomes. A total of 2,971 patients were included in the study. The data revealed that participation in formal PT accounts for up to 8% of the episode of care following THA and TKA. For most patients, the role of formal PT should take into account the cost-effectiveness of the intervention. Yayac, et al., Formal physical therapy following total hip and knee arthroplasty incurs additional cost without improving outcomes. Journal of Arthroplasty | July 16, 2020 WHAT WORKS BEST FOR ROTATOR CUFF TENDINOPATHY: HIGHER OR LOWER EXERCISE DOSE? By analysing relevant randomised controlled trials, researchers compared higher exercise dose, including higher exercise load and/ or higher volume, vs lower exercise dose



(lower load and/or lower volume) in terms of effectiveness and harms in patients with rotator cuff tendinopathy. Three trials (N = 283) were analysed. As per low certainty evidence, higher load and volume exercise afforded improved function at three months, but little or no clinically important between-group difference was reported for activity or night pain. Overall, only few studies assessing higher dose exercise for rotator cuff tendinopathy were available. Regarding the worth of higher vs lower dose exercise for patients with rotator cuff tendinopathy, low to very low certainty and conflicting evidence was found.

volved mechanism, due to the link between H2RA use and kidney stone risk. Prescribing for most patients will not need to be changes since the effect is small.

Malliaras P et al., The efficacy of higher vs lower dose exercise in rotator cuff tendinopathy: A systematic review of randomised controlled trials. Archives of Physical Medicine and Rehabilitation | July 18, 2020

A cohort study was conducted to assess the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at the surgery in patients with lumbar disc herniation and associated radiculopathy (DHR). In this study, disc material from patients with DHR undergoing lumbar discectomy was sampled and had undergone histological/immunohistochemistry analyses. Three controls patients and 40 patients with DHR were recruited. None of the control discs had evidence of inflammation compared to 28% of patients with DHR. Predictors of the presence of histologically confirmed inflammation included back pain < 5/10, symptoms worse the next day after injury, lumbar flexion range between 0 and 30° and a positive clinical inflammation score (at least 3 of: constant symptoms, morning pain/stiffness greater than 60-min, short walking not easing symptoms and significant night symptoms). The model achieved a sensitivity of 90.9%, a specificity of 92.9%, and a predictive accuracy of 92.3%.

USE OF PROTON PUMP INHIBITORS INCREASES RISK OF INCIDENT KIDNEY STONES Whether and how proton pump inhibitor use is related to kidney stones was examined in this retrospective analysis utilizing data from the Women’s Veteran’s Cohort Study. Data regarding proton pump inhibitor usage over time, demographics, laboratory findings, comorbidities, and medication usage were obtained from 465,891 patients. Use of histamine-2 receptor antagonists (H2RAs) was determined and levothyroxine use was a negative control exposure. Greater risk of kidney stones was observed in relation to increased dosage of PPI. Increased risk was also noted in correlation with H2RAs. In adjusted analysis, there was no link of levothyroxine use with kidney stones. Overall, proton pump inhibitor use was identified to be related to a dose-dependent rise in kidney stone risk in a large cohort study of veterans. Acid suppression may be an in-

Simonov et al., Use of proton pump inhibitors increases risk of incident kidney stones. Clinical Gastroenterology and Hepatology | August 7, 2020 CLINICAL FEATURES AS PREDICTORS OF HISTOLOGICALLY CONFIRMED INFLAMMATION IN PATIENTS WITH LUMBAR DISC HERNIATION WITH ASSOCIATED RADICULOPATHY

In view of the inconsistent results from epidemiological studies on the correlation between coffee intake and cancer risk, researchers sought to summarize and evaluate the quality of the current evidence via performing an umbrella review of existing findings from meta-analyses of observational studies. Searching PubMed, Embase, Web of Science and the Cochrane database, they retrieved 28 individual meta-analyses including 36 summary associations for 26 cancer sites for this umbrella review. Significant associations were evident for five cancers in dose-response analyses. An inverse correlation of coffee intake with the risk of liver cancer and endometrial cancer was observed and this was characterized by dose-response relationships. Zhao LG, et al. Zhao LG, et al. Coffee drinking and cancer risk: An umbrella review of meta-analyses of observational studies. BMC Cancer | February 11, 2020 RESTRICTING CALORIES HELPS BLOOD PRESSURE AND CARDIOVASCULAR FUNCTION. Researchers investigated how caloric restriction can impact blood pressure (BP) and cardiovascular function by analysing human RCTs. They identified RCTs where adults got a calorie-restricted intervention vs a control/ standard diet by exploring Medline, EMBASE, CINAHL (up to June 2017). Overall, 32 RCTs with 1,722 participants were included in the analysis. They found the largest impact on systolic and diastolic BP with calorie-restricted interventions lasting 1–4 weeks, but HR remained unaffected with these diets. Findings revealed that the observed changes in B/P in response to 1–4 weeks of calorie restriction were comparable to that anticipated with medications, and greater than that documented for other lifestyle interventions or supplements. Comparable effects on BP with a reduction in HR as well was seen with interventions lasting 1.5–6 months had. Kirkham et al. The effect of caloric restriction on blood pressure and cardiovascular function: A systematic review and metaanalysis of randomized controlled trials. Clinical Nutrition | July 11, 2020

Ford et al. Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy. BMC Musculoskeletal Disorders | August 25, 2020 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




com/andersonchiromackay/ or www. Email admin@ to apply.


VIC – Elwood: Are you a dynamic & motivated Chiropractor? Are you fun, personable & outgoing with a desire to excel in private practice. If you answered yes then this is the role for you. 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 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. Contact Michaela via hello@thisislifewellness. or (03) 9531 5050.

QLD – Sunshine Coast: Recent Graduate associate position available for Sunshine Coast Hinterland Glasshouse Country Chiropractic is seeking a recent or new Graduate. This position is based on the Sunshine Coast. The successful applicant will alternate between two busy clinics based 30 km apart in the townships of Glasshouse Mountains and Woodford so must have their own transport. The associate will be expected to work unassisted after the initial training period. Ongoing adjusting technique training and mentoring will be available. Income will be based on a percentage of total gross earnings. Must be AHPRA registered and have own professional indemnity insurance. A rural background and manual adjusting techniques would be preferred. If you believe that this position suits you, please send your resume to woodfordchiro@ NSW – Mid North Coast: A unique associate position, situated on the Mid North Coast, NSW would be suited to a motivated, energetic chiropractor with substantial work and community-based ethics. Associate required for our well established Evidence-Based Chiropractic and patientcentred clinic. Both principals are university academics teaching within the chiropractic and physiotherapy programs. Our clinics enjoy an excellent reputation and have been established in the local communities for over 20 years and are enjoying many referrals from health care professionals. Both new and experienced graduates are welcome to apply. You must be prepared to travel some distance and available for weekend work. The position is suitable for a chiropractor who is committed to hard work and a positive attitude. Email your CV and cover letter to Dr Darren Gray at darren@ QLD – Mackay: Anderson Family Chiropractic is seeking a Chiropractor for our clinic in Mackay. We Offer: • $70,000 gross retainer, replaced with 50% + GST when in excess of retainer • $1000 yearly extended-learning allowance • Financial aid for relocation costs • The successful applicant: • Adept manual adjuster, skilled with Activator and soft tissue therapy • Certification in Dry Needling or willingness to obtain See our clinic at https://www.facebook.



NSW – Newcastle: We are looking for a Chiropractor to join our well-established practice located in Newcastle. We are primarily a diversified and soft tissue practice, with other techniques utilised such as dry needling. Ideal qualities include having excellent manual skills, confidence, passionate, good-natured, and motivated. We are seeking someone looking for a long-term position. The new associate will be taking on some of the primary chiropractor’s clients, as well as building their own clientele from our regular influx of new patients. Both experienced and new grads are welcome to apply. Send your CV to: Singapore: Associate chiropractor opportunity in Singapore - We are an established and growing practice, looking for an ENTHUSIASTIC AND CONFIDENT chiropractor to join our team. Our practice is predominantly family based with a strong focus on wellness care. Techniques used include Diversified, Thompson and Activator. We prefer someone with at least one year of experience, however new graduates are welcome to apply. Training and mentorship provided. Base salary with high commission scheme. The successful applicant will possess excellent adjusting skills. He/she will be a good communicator, motivated, independent and initiative. Website: If you are interested, please send a cover letter and resume to NSW – Berowra Heights: MATERNITY COVER/LOCUM/ASSOCIATE POSITION We are looking for an associate to cover for a full time chiropractor going on maternity leave from December. We are an established

evidence-based clinic in Berowra Heights working alongside a local GP practice and other allied healthcare professionals. We need someone who can confidently work autonomously with strong communication and diagnostic skills. Minimum full time for 8 months. You must be a confident manual adjuster and utilise activator, drop and soft tissue techniques. Not essential but highly regarded — keen interest in headache and migraine management. If you are interested please email Susie with your cover letter and CV to QLD – Brisbane & Sunshine Coast: Tyack Health is seeking a passionate practitioner to join our dynamic team, offering: • • • •

Large established patient base Engaging, team learning environment Large multi-disciplinary team Opportunity to make a meaningful difference • Eco – friendly practice • Competitive remuneration package Located in Manly West, south of Brisbane city, and on the Sunshine Coast. Opportunity to work in either location. Visit https://www. To apply, please send your letter and resume to jennyhoneyman@tyackhealth. For further information, please view our website or call (07) 3249 5321 NSW – Caringbah: Associate required with competent diagnostic, strong manual adjusting and soft tissue modality skills to work alongside nutritionist and pregnancy masseuse in evidence-based Caringbah practice. Diverse client base. Well established clinic (42 years) that recently branched out to Kensington. Interested applicants to: NSW – Central Coast: ASSOCIATE position with Complete Health Clinic. Work alongside 3 osteopaths, Remedial Massage, Pilates. Cliniko software with full reception. Situated in Mariners Centre of Excellence in Tuggerah. Part time or Full time. Immediate start or January 2021. Send CV to Troy Fleming at www.completehc. NSW – Rozelle: Wonderful, ideally experienced Chiro wanted to take over client base from long standing practitioner in Inner West Rozelle. Large multi modality practice with highly passionate and focused team – Health Space. Call Director Dr Nick Wood 0402 829 081 or email on for more information. QLD – Brisbane: INTERSTATE RELOCATION COST COVERED FOR

CLASSIFIEDS THE RIGHT CANDIDATE Elite Health and Performance is growing and we are excited to offer a role to our new chiropractic superstar! But why choose Elite? • Weekly mentoring to develop your personal and professional skills from your team leader to develop clinical skills, expand your repertoire of modalities and enhance your diagnostic ability. • A generous salary with no pressure of commission style work. • Be a part of a young and vibrant team – learn and thrive with experts in sports therapy and rehabilitation. • Be a part of a team that values having fun and making the most out of each day. • Learn ART and other STW techniques from highly experienced clinicians. Elite Health and Performance is one of Brisbane’s top allied health clinics highly regarded within the health and fitness industry. We treat a wide range of sports injuries as well as common postural complaints. We use techniques such as manipulation, soft tissue therapy, dry needling, fascial abrasion and exercise rehabilitation. If this sounds like your dream role then send your resume to QLD – Gold Coast: Robina Chiropractic Wellness Centre – Gold Coast. Full time chiropractic position. Salary plus Bonus. Check out our Facebook ad: https:// posts/3105591009529704 or contact me on and I’ll tell you how to apply. QLD – Brisbane: Chiropractor required for a busy holistic health practice located in Newstead, Brisbane. Must be AHPRA registered and have own professional indemnity insurance. You will be passionate and enthusiastic to accept a range of patient cases. In return you will be provided with experienced support staff and a friendly working environment. Please email hello@ if you would like to apply or would like further information. NSW – Enmore: ChiroRelief based in Enmore, Sydney is looking for a part time chiropractor to join our team to take over the head practitioner’s patient base, when she goes on maternity leave in 4 months. The successful candidate will have to be proficient at manual adjusting full spine, have a maintenance/wellness philosophy with the ability to keep patients engaged in their health journey. We use spinal decompression/automated flexion distraction, manual adjustive techniques plus mobilisation techniques, dependent on the case, with the addition of dry needling and cupping and soft tissue techniques. Training

will be provided however some background knowledge in these areas will be useful. We are looking for a long-term addition to our clinic, who shares our love for chiropractic and an ability to think outside the box. Superstar new Grads are welcome to apply. Please send resume to chiroshiyab@gmail. com

your CV (with references) and any questions to:

QLD – Gold Coast: Gold Coast Associate Position: Join our highly regarded evidencebased 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. Above average remuneration. Call (07) 5559 1998. Email mudgeeraba@


NSW – Blacktown: Fantastic opportunity for a Chiropractor with strong manual adjustment skills to walk into an existing client base and lots of new clients (av. 12 – 15 per week) in a clinic in Westpoint Shopping Centre, Blacktown. Flexible hours, support staff, great opportunity to leverage of the existing database. If interested message Benny on 0433 672 317.

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 at or call 1800 908 903

Check out our website for more info https:// employment-opportunities/chiropracticassociate/

VIC – Inner Melbourne: Inner-city practice servicing 50 quality patients a week (28 hours per week across 3.5 days). Includes 2-bedroom residence upstairs or option for additional consulting rooms. Practice has continued to grow organically with minimal marketing. Contact anthonylee@


NSW – Armidale: Chiropractic Associate for Wholesome Health Chiropractic. A sensational opportunity to work in a busy sports chiropractic clinic in Armidale NSW. With a university, airport (to Brisbane and Sydney), an abundance of schools, stunning national parks and did I mention a 5 min commute to work? If the last few months have got you questioning your city lifestyle, then look no further than the relaxing, laid back and wide-open spaces Armidale’s country lifestyle has to offer. As a sports chiropractic clinic we use a wide range of modalities. If you have an interest or experience with dry needling, K-tape/ rocktape, IASTM, soft tissue techniques, clinical pilates, rehabilitation and women’s health, then we’d love to hear from you. We have an overflowing patient base (there is currently a 3 week wait to see the Principal chiropractor!) as our most recent associate left suddenly to be closer to friends and family. In addition, there are healthy referrals from various gyms, sporting teams, GP’s and allied health therapists so there is no shortage of patients (even in this current climate!) At Wholesome Health we offer both 15 and 30-minute consults. The clinic is open Monday- Friday with flexible hours with the choice of working full or half days. If this interests you then we’d love to hear from you. Please email a cover letter with

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