Keep Current with Short, Concise, Video Presentations. Coffee Break Presentations are video presentations between 10-15 minutes in length that ensure focus and interest remain intact. Thomas Souza, D.C., author of Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms, 5th edition, presents information in a concise and cogent format. In addition to in-office chiropractic care, chiropractic practitioners have an obligation, as holistic practitioners, to provide patients with individualized, evidence-based adjunctive lifestyle interventions to help them live a longer, quality-filled life, combat existing health problems and reducing onset of conditions they might be.

MethodsAn expert consensus process was conducted from August-October 2013 using the Delphi method. Panelists were first provided with background literature, consisting of three review articles on manipulation under anesthesia.

The Delphi rounds were conducted using the widely-used and well-established RAND-UCLA consensus process methodology to rate seed statements for their appropriateness. Consensus was determined to be reached if 80% of the 15 panelists rated a statement as appropriate. Consensus was reached on all 43 statements in two Delphi rounds. IntroductionSpinal manipulation under anesthesia (MUA) is a procedure that was originally practiced by orthopedic surgeons and osteopathic physicians for the treatment of spinal pain since the late 1930’s ,.

Since the 1960’s, Doctors of Chiropractic (DC) have come to perform the majority of spinal MUA procedures. Fibrosis Release Procedures is a term which includes MUA and perhaps better describes the comprehensive nature of the procedures used by DCs in performing MUA, since more than spinal manipulation is involved.There are currently no widely accepted guidelines on standards for chiropractic MUA. The 1993 Guidelines for Chiropractic Quality Assurance and Practice Parameters considered MUA “equivocal”, and these guidelines have not been updated since 1993. In 2012, the American Association of Manipulation Under Anesthesia Providers (AAMUAP), a multidisciplinary panel of MUA experts, developed a set of guidelines for the practice, and educational parameters for MUA. Members of the organization undertook a further effort to develop a set of evidence-informed and consensus based guidelines developed by a panel of multidisciplinary experts, including MUA practitioners as well as experts who were not MUA practitioners. The results of this consensus process are presented in this article.Although MUA has been said by some authorities to be “a reasonable method of treating certain patients with spinal pain”evidence for its effectiveness is limited, with few controlled studies. However, the studies that exist, the majority of which are case series, have shown positive results ,.

In the absence of higher levels of evidence, or when the published literature does not provide adequate detail about management parameters, formal consensus by experts can be useful ,. Indications for MUAA concern in providing MUA is the lack of standardized protocols for patient selection.

Selecting the patient who will benefit most from MUA is essential to the success of the procedure, yet selection criteria have not been investigated thoroughly. Generally, spinal MUA is used for patients who suffer from chronic nonspecific mechanical spine-related pain who have been minimally responsive (not reaching the expected level of outcome) to previous conservative therapy; this is considered a treatment failure for conservative therapy ,. Etiology of their pain may be disc bulge/herniation, chronic recurrent sprain/strain, failed back surgery, or myofascial pain syndromes.

The procedure is considered by many practitioners to be beneficial for the patient who has muscle spasm accompanied with pain and loss of terminal joint range-of-motion. These types of patients typically respond well to manipulation/physical therapy/exercise, but their relief may only be temporary.Hallmarks for choosing a patient for MUA are 1) the presence of intersegmental and/or global recalcitrant motion restrictions that are thought to be fibrosis maintained, and 2) the unsuccessful attempt at more conservative measures that have included in-office spinal manipulation. Description of MUA procedures and follow up careAnother concern is the lack of standardization of MUA procedures and follow-up care. It is well-established that MUA requires an interdisciplinary team which includes an anesthesiologist, an operating room (OR) nurse and a DC or other qualified manual therapy physician. It is also generally accepted that the phases of MUA are 1) sedation; 2) manipulative procedures; 3) additional stretching/traction procedures; 4) follow-up in-office care without sedation. Manipulative and additional proceduresThe patient is taken through passive spinal, hip, shoulder, and extra spinal extremity ranges of motion, determined by the treating physician. Specific spinal manipulation is performed when the elastic barrier of resistance and segmental end range of motion is achieved.

Stretching of the paraspinal and surrounding supportive musculature is performed to promote cervical, thoracic, lumbar, lumbopelvic and extra spinal flexibility in conjunction with attempting to restore proper kinetic motion. The patient is then awakened from the anesthesia which usually occurs minutes after the Diprivan (propofol) is stopped.

They are then taken to recovery and monitored until full recovery has occurred. The patient is then discharged to rest until post MUA therapy is begun later the same day (or in as short a time as possible following MUA).

Follow-up care without sedationPost MUA therapy is an essential part of the MUA procedure and is accomplished the same day, if possible. Post MUA therapy consists of warming up the involved areas, passive stretching as was accomplished in the MUA procedure, followed by interferential stimulation and cryotherapy. The patient is then sent home to rest. This procedure is repeated serially in most cases by having the patient return to the facility the next day and the following day(s). The average number of days for the MUA procedure to accomplish the desired outcome has been shown to be between 2-4 days ,. The concept is that increasing movement each day in incremental amounts accomplishes the desired increase in range of movement and decreases pain far better than spending large amounts of time in one day to achieve the same result. This protocol for post MUA therapy is repeated 7-10 days after the final MUA followed by pre-rehabilitation and then formal rehabilitation for 3-6 weeks.

Additional reduction in soreness and mild edema with an increase in range of motion has been noted when small, portable, multi-modality interferential/NMES/HVPC or TENS devices are applied in the OR immediately following the MUA and when the patients are sent home with these units as part of the post MUA therapy ,. The rehabilitation program continues for 3-6 weeks following the MUA procedure to give the patient time to recover to pre-injury status. Marked improvement (80-97%) has been the general rule when the properly selected cases have received this procedure ,. Evidence for MUA treatment effectsA PubMed literature search using the term “manipulation under anesthesia” found 2 systematic reviews (2002 and 2008 ) and one narrative reviewand no articles that were not addressed in the reviews ,. The secondary sources (reviews) , were the primary references used for evaluating the evidence related to MUA, with emphasis on the most recent review (2013). Although it did not claim to be a systematic review, it did evaluate the strength of the existing evidence on the topic. The evidence was assessed using the scheme described in the 2003 Journal of Bone & Joint Surgery, which is commonly used in musculoskeletal medicine.

Definitions of the levels of evidence in this scheme are summarized in Table.Source: Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. Jan 2003;85-A(1):1-3.Abbreviations: RCT randomized controlled trial, SR systematic review, CC case control study.1For this project, case reports were classified as the same level as expert opinion.The evidence for treatment effects of MUA consisted of Levels II, IV and V. Level II evidence included three prospective cohort studies and - three reviews (narrative review, 2013) and (systematic reviews 2008 and 2002).

The remaining published literature on MUA consisted of Level IV studies (case series) and Level V studies (case reports and expert opinion). Overall, positive effects were noted for MUA in appropriately selected patients; however, the absence of control groups make it impossible to make a definitive assessment. Delphi consensus panelThe project was determined to be exempt (P/N 2013-017) by the Institutional Review Board of Life Chiropractic College West prior to conducting the Delphi process. An expert consensus process was conducted using the Delphi method. Because a Delphi panel is made up of experts, we selected individuals on the basis of their established expertise in the area of spine-related care.

We identified both individuals who practice MUA and those who provide spinal care without MUA, to avoid bias toward MUA practice. We also included laypersons familiar with spine-related care, such as insurance specialists and attorneys. A list of 24 panelists to be invited included healthcare providers who had published on MUA, were MUA practitioners, were experienced DCs who did not practice MUA but had a practice emphasis in chronic spinal pain and were familiar with guideline development, and several laypersons with healthcare experience such as insurance specialists and attorneys.

Medical doctors (MD) (anesthesiologists and other specialists), osteopathic and chiropractic physicians were included, as well as registered nurses (RNs). A total of 16 panelists accepted, of which 10 (63%) were DCs. Panelists included 1 MD anesthesiologist, 2 MDs in other medical specialties, 2 RNs who work on MUA teams, 6 DCs who practice MUA, 4 DCs who do not practice MUA, and 1 attorney. Of the DCs, all were practitioners and 5 were also on the faculty of 5 different chiropractic colleges. There were 13 (81%) male and 3 (19%) female panelists, with a mean of 23 years professional experience (median 25 years). States represented were CA (5), FL (4), TX (2) and 1 each from GA, NC, NY and RN; one panelist resides in Malaysia. Most of the DCs were broad-scope in terms of practice approach, meaning that they utilized a number of procedures in addition to manipulation.

Delphi processThe Delphi process was conducted by e-mail. Each set of seed statements to be rated was identified by an ID number. Only the project coordinator could link the ID to the panelist’s names, for purposes of distribution and follow-up. The Delphi process was conducted in a blinded manner, so that neither the panelists nor the core committee knew the identity of the raters or those who had made any individual comments, during the development of consensus. We used the widely-used and well-established RAND-UCLA consensus process methodology in rating the seed statements. We used an ordinal rating scale ranging from 1 (highly inappropriate) to 9 (highly appropriate).

We explained that by “appropriateness” (as specified by RAND/UCLA) , “we mean that the expected health benefit to the patient exceeds the expected negative consequences by a sufficiently wide margin that it is worth doing, exclusive of cost”.In scoring, ratings of 1-3 indicated “inappropriate”; 4-6 “undecided”; and 7-9 “appropriate”. Panelists rating a statement as “inappropriate” were required to give a specific reason and, if possible, provide a reference from the peer-reviewed literature to support it.

There was unlimited space provided for panelists to make comments, and the project coordinator entered all comments into a Word file, identified by ID number, rating and seed statement number. The project coordinator entered the numerical ratings into an SPSS v. 21.0 database and one of the investigators (CH) analyzed the results, computing the median rating and percentages of agreement for each statement.

We considered consensus present when both the median rating was 7 or higher and at least 80% of the panelists gave a rating of 7 or higher. Rounds were to be repeated until consensus was reached.The core committee reviewed all comments and revised the statements on which consensus was not reached, based on the panelists’ comments. The project coordinator then circulated the revised statements, along with the de-identified comments, to the entire panel for the next round. General guideline disclaimerThis guideline is intended for practitioners, facilities, and other interested parties. Decisions to adopt particular courses of action must be made by trained practitioners on the basis of the available resources and the particular circumstances of the individual patient. This guideline is not to be applied to any specific patient, in any manner, and any decision requiring necessary testing, patient candidacy or follow-up procedures must be made by the individual doctor and determined by the needs of the patient. Safety and effectiveness should drive the doctor’s decision when considering Manipulation Under Anesthesia protocols.

This guideline is not intended for utilization review purposes. The American Association of Manipulation Under Anesthesia Physicians denies responsibility for any injury or damage resulting from actions taken by practitioners after considering this guideline.

Patient selection: clinical candidacy for MUAThe following factors qualify a patient for clinical candidacy for MUA. The patient has undergone an adequate trial of appropriate care, usually including spinal manipulation by a chiropractor, and often with medical co-management, and continues to experience intractable pain, interference to activities of daily living, and/or biomechanical dysfunction. Sufficient care has been rendered prior to recommending MUA. A sufficient time period is usually considered a minimum of 4-8 weeks, but exceptions may apply depending on the patient’s individual needs. Establishing medical necessityEvery condition treated must be diagnosed and justified by clinical documentation in order to establish medical necessity. Documentation of the patient’s progress and the patient’s response to treatment are combined to confirm the working diagnosis. Patient safetyMUA is performed using the anesthesia techniques determined by the anesthesiologist to be appropriate for the patient. MUA is performed with the patient in a sedated state as determined safe and effective by the attending anesthesiologist.

The chiropractic providers do not make any decisions regarding the medical management nor do they direct or use any of the medications required by the anesthesiologist during his or her medical management.The primary doctor and the co-attending doctor move the patient into specific ranges of motion to accomplish the procedure. In this capacity, the patient depends on the primary doctor and co-attending doctor to protect them from bodily injury.

This means that all the pronunciations of the examples have been copied onto your computer.b.) have installed using the 'Recommended' installation and have CD 2 in the CD-ROM drive of your computer.If you have installed using a 'Minimal' or 'Medium' installation, you will not be able to hear the example sentences. If you want to also hear sentences examples pronounced in ‘recommended’ installation, you must have CD 2 in the CD-ROM drive of your computer.c.) If you have installed using the 'Medium' or 'Minimal' installation, you will need to keep CD 1 in the CD-ROM drive of your computer.If you want to hear the example sentences you must eithera.) have installed using the 'Full' installation. All headword pronunciations have been copied onto your computer. Longman dictionary of contemporary english no cd patch.

Since the patient is only minimally responsive to painful stimuli and does not have the ability to respond to immediate proprioceptive input, both the primary doctor and the co-attending doctor are key to a safe and successful procedure.The co-attending doctor is responsible for patient stability, patient movement, patient observation, and completing portions of the procedure should the primary doctor need assistance or become unable to perform the procedure. Since there are several instances during the procedure when the primary doctor has to move the patient, stabilizing and working with the patient would be unsafe without assistance from another doctor competent and knowledgeable in MUA. Doctor safetyManipulation under anesthesia is a very physically demanding therapeutic procedure. Since the patient is in a sedated state, the doctor has the added responsibility of insuring that the patient’s extremities and torso do not fall from the treating surface.

The doctor must also be able to move the patient without the assistance of the patient.The co-attending doctor is an integral part of this procedure and is responsible for helping the primary doctor move the patient through the prescribed ranges of motion. The co-attending doctor is present to insure that all movements are accomplished without injury to the patient or to the primary doctor performing the procedure. As a result of the added potential risk to the patient in a sedated state, there is a high risk of injury to the doctor and the patient if only one doctor were to attempt the complex techniques necessary for the MUA procedure. Inclusion of a co-attending doctor, who is a certified MUA practitioner, is the safest way to perform this procedure. It may be unsafe to perform an MUA without a competent and knowledgeable MUA doctor as the co-attending doctor and anything other than allowing another MUA certified doctor to act as a co-attending doctor imposes potential risks. By using a certified MUA practitioner as a co-attending doctor, optimal effectiveness and safety standards are maintained. This is proper standard of care policy for the MUA procedure and needs to be recognized as such by anyone recommending MUA, or reimbursing for MUA.In the cervical spine, the co-attending doctor must secure the patient’s shoulders and provide counterforce procedures to obtain the necessary traction for this part of the procedure.

In the thoracic spine, the co-attending doctor turns the patient, stabilizes the patient and applies proper counter traction for the MUA maneuvers. In the lumbosacral area, the co-attending doctor coordinates movements with the primary doctor, assists with the actual procedures, and can complete the MUA procedures as necessary. Procedure efficacy is enhanced when both doctors are trained and knowledgeable regarding the appropriate forces and counterforces required to perform safe and effective MUA procedures.A certified MUA physician carries the appropriate malpractice insurance to perform MUA and so does his or her co-attending doctor. Since non-certified assistants may not carry malpractice insurance for MUA, utilization of ancillary staff to assist with the MUA procedure may potentially place the entire team and the facility at risk. Therefore, only a certified MUA practitioner should co-attend the MUA procedure. Pre-MUA anesthetics procedures. Patients are appropriately evaluated by their chiropractic or MUA doctors to assess candidacy prior to the procedure.

Anesthesiologists will typically perform a history and physical prior to the procedure and may elect to not go forward with and may cancel the procedure if they feel that the patient might be at risk from a medical standpoint. All appropriate clearance forms, laboratory results, imaging reports and other supported data are available for review in the patient’s chart. Special testing should be provided only as deemed necessary and based on individual needs.

Since the fibrosis release from manipulative procedures performed during MUA carries similar risks as chiropractic in-office procedures, the need for diagnostic tests is commonly determined using similar criteria as might be performed during in-office care with physical methods. Individual laboratory testing or special testing requirements may differ from state to state or from facility to facility. DiscussionSimilar to many other treatments available for spinal conditions, MUA does not have the unequivocal support for effectiveness and efficacy that would be provided by multiple randomized controlled trials and meta-analyses. If proven alternatives that addressed these same conditions were available, other choices would be recommended prior to considering MUA.However, there is a fair amount of lower-level evidence in regards to the safety and efficacy of this procedure. This led Dagenais et al. In their systematic review to state: “However, almost all studies to date on these procedures have reported positive results, indicating that patients who undergo their procedures have a reasonable prognosis” , p.

148.In the absence of strong evidence, this guideline was designed to provide recommendations on best practices of MUA for interested and affected parties; namely, patients, doctors, and payers.When a doctor or patient considers MUA, he/she is commonly comparing the appropriateness of this procedure to many other procedures with a similar evidence level for support. Kohlbeck, et al., in their systematic review expressed this consideration for practitioners:“Medicine-assisted spinal manipulation therapies have a relatively long history of clinical use and have been reported in the literature for over 70 years. However, evidence for effectiveness of these protocols remains largely anecdotal, based on case series mimicking many other surgical and conservative approaches for the treatment of chronic pain syndromes of musculoskeletal origin.

There is, however, sufficient theoretical basis and positive results from the case series to warrant further controlled trials on these techniques” , p. 288.Payers are also faced with challenges when considering reimbursement for MUA procedures. This is also summarized by Kohlbeck, et al. As follows:“If a clinician recommends or offers, and a payer reimburses, surgery, injections, epidurals, and certain physical therapy approaches, to a patient without requiring substantial proof of effectiveness and safety, then it would be difficult to deny the use of medication-assisted manipulation or fail to reimburse for it It would seem unreasonable, however, to hold medication-assisted manipulation to a higher standard of scientific rigor than that required of other treatment approaches” , p. 301.The Delphi panel who developed this guideline was composed of experienced physicians, nurses and educators, both practitioners of MUA and practitioners who do not practice MUA but are experienced in the treatment of spine-related pain. This group reached a high level (80%) of consensus on recommendations related to the practice of MUA. This lends clinical validity to the recommendations and therefore should guide MUA practitioners.

This guideline is not intended to be prescriptive, or to suggest that MUA is the only therapy of choice when seeking relief for spinal dysfunction and pain. It is intended to provide practitioners with evidence-informed, consensus-based parameters guiding the use of MUA. Competing interestsThe American Association of Manipulation Under Anesthesia Providers provided consultant fees for Dr. Hawk’s role on the project. She served as an independent contractor to the project, which is not associated with her position at Logan University. RG and EC have no financial interest in any part of the process and have not received any remuneration for their part in this project.

Both RG and EC practice manipulation under anesthesia and teach it in post-graduate education. The authors declare that they have no competing interests. Authors’ contributionsRG developed the original seed statements, contributed to the literature search, participated in conducting the Delphi rounds, and was the primary author of the paper. EC also developed the original seed statements, contributed to the literature search, participated in conducting the Delphi rounds, and contributed to writing the paper.

CH conducted the Delphi rounds, contributed to the literature search and contributed to writing the paper. All authors read and approved the final manuscript. AcknowledgementsThe authors thank Michelle Anderson for coordinating the conduct of the Delphi process, and the Delphi panelists for generously contributing their time and expertise to the consensus process: Donald Alosio, DC; E. Graham Baker, Jr, JD; Ulyss Bidkaram, DC; Ian Brown, MD; Charles Davis, DC; Sarb Dhesi, DC; Robert Francis, DC; Kathryn Hoiriis, DC; Michael Hubka, DC; Tom Hyde, DC; Rita Iwanski, RN; John LaFalce, DC; Ramses Nashed, MD; Michael Ramcharan, DC, MPH; Susan Rhodes, RN; Richard Skala, DC; Ronald Wellikoff, DC; David Wolstein, MD. Greenman PE. Manipulation with the patient under anesthesia. J Am Osteopath Assoc.

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Evidence-based practice has had a growing impact on chiropractic education and the delivery of chiropractic care. For evidence-based practice to penetrate and transform a profession, the penetration must occur at 2 levels. One level is the degree to which individual practitioners possess the willingness and basic skills to search and assess the literature. Chiropractic education received a significant boost in this realm in 2005 when the National Center for Complementary and Alternative Medicine awarded 4 chiropractic institutions R25 education grants to strengthen their research/evidence-based practice curricula. The second level relates to whether the therapeutic interventions commonly employed by a particular health care discipline are supported by clinical research.

A growing body of randomized controlled trials provides evidence of the effectiveness and safety of manual therapies. The use of complementary and alternative medicine has increased dramatically during the past several decades., Estimates based on the 2002 National Health Interview Survey reveal that 62.1% of US adults used complementary and alternative medicine therapies during the previous year. Chiropractic is the largest complementary and alternative medicine profession in the United States, with approximately 70 000 members, and chiropractic services account for the greatest number of complementary and alternative medicine visits. In 2002, approximately 7.4% of Americans consulted a chiropractor for treatment.

Chiropractic is a well-established part of the health care delivery system, included under Medicare and Medicaid laws, with worker’s compensation coverage in all 50 states. Insurance coverage for chiropractic is also quite extensive. Approximately 50% of health maintenance organizations and 75% of private health insurance plans cover chiropractic care.Over the past 10 to 15 years, evidence-based practice has had increasing influence on the chiropractic profession. A number of events and trends have converged to account for this phenomenon. Starting in the 1990s, a growing body of clinical research has offered support for the application of manual therapy for various musculoskeletal conditions, particularly low back pain. Consequently, manipulation has been included as an effective care option in a number of national and international guidelines on low back pain., Additional research in related fields such as orthopedic assessment of the spine and extremities, exercise therapy, and biomechanics of the adult spine has also affected the profession.

As outcomes research has steadily increased, it has become more common for individual chiropractors to use evidence-based outcome measures such as validated questionnaires to measure activity limitations. In a cross-discipline study, chiropractors (along with physical therapists) were more likely than general medical practitioners to use Roland Morris or Oswestry Disability Questionnaires in assessing low back pain.At the same time, larger events, such as inclusion of chiropractic services in the Veterans’ Health Administration, Defense Department, and hospitals throughout the United States, have sparked a need to encourage cooperation between the medical and chiropractic professions. Nearly all chiropractors report that they refer patients to other health care providers. They also report receiving referrals from medical physicians.

Family practitioners were the most likely physicians to refer to a chiropractor, followed by family nurse practitioners, internists, neurologists, neurosurgeons, gynecologists, and general surgeons.The primary purpose of this article is to provide an overview of the growing impact of evidence-based practice in chiropractic care. Arguably, for evidence-based practice to penetrate a profession, the penetration must occur at 2 levels. One level is the degree to which individual practitioners possess the willingness and basic skills to search and assess the literature.

The second level relates to the degree to which research evidence supports the therapeutic interventions commonly employed by a particular health care discipline. Model of Chiropractic CareChiropractors are licensed as primary-contact, portal of entry providers in all 50 states and are trained to triage, differentially diagnose, and refer cases not amenable to chiropractic care. The current model of chiropractic health care is holistic with a focus on the evaluation and conservative treatment of musculoskeletal disorders. Although there is significant variation in scope of practice from state to state, nearly all chiropractors use a variety of manual therapies with an emphasis on spinal and extremity joint manipulative procedures. Patients with musculoskeletal complaints are assessed using standard history and physical examination procedures. Special consideration is directed to the orthopedic and neurological components of the physical examination, incorporating direct assessment of articular soft tissues and joint play in order to determine whether the patient is a candidate for manual therapies.For basic musculoskeletal injuries and postural syndromes, chiropractors use 4 broad categories of therapeutic interventions: ( a) joint manipulation and mobilization, ( b) soft tissue manipulation and massage, ( c) exercise and physical rehabilitation prescription, and ( d) home care and activity modification advice. In addition, nutritional and dietary counseling, physical therapy modalities (eg, heat, ice, ultrasound, electromodalities), and taping/bracing are also used as adjunct procedures.

A 2003 survey of US chiropractors by the National Board of Chiropractic Examiners reported that spinal complaints were the most common conditions seen (53.8%), followed by extremity complaints (17.1%) and headaches or facial pain (12%). Chiropractic EducationChiropractic education is regulated by the Council on Chiropractic Education (CCE) under the US Office of the US Department of Education. Entrance requirements for accredited institutions require a minimum of 3 years of college credits. Prerequisite coursework includes 24 semester hours in basic sciences, including biology, chemistry, and physics, and 24 semester hours in humanities and social science.The chiropractic educational program is a minimum of 4 years.

All Council on Chiropractic Education-accredited institutions provide a curriculum incorporating elements of basic science (eg, physiology, anatomy, and biochemistry), clinical science (eg, laboratory diagnosis, radiographic diagnosis, orthopedics, neurology, and nutrition), and clinical intern experience. Evidence-Based Practice SkillsAlthough all 4 institutions have followed different approaches to implementation, the overall strategies share some common principles. ( a) Course work should incorporate journal club formats, checklist reviews of current studies, and student construction of critical appraised topics. ( b) Informational literacy assignments should span all 4 years, be relevant, and relate to other course content. ( c) The language and concepts of evidence-based practice must permeate all diagnosis and management courses and, where feasible, basic science courses as well. ( d) Focused and ongoing training must target a large proportion of classroom and clinical faculty across the entire school curriculum.

( e) Application of these skills must be patient based and become part of the clinic culture as opposed to an endeavor segregated to a journal club activity. Low Back PainSpinal manipulation is an effective care option for acute, subacute, and chronic low back pain. Massage was also found to be effective for chronic low back pain.

Notably, these finding were based, in part, on the clinical practice guidelines developed for the American Pain Society and the American College of Physicians. Chou et al, recommended these treatments in addition to medical care. The most recent meta-analysis was supportive in finding clinically meaningful differences in aggregate between manipulation and other treatment alternatives.

A 2010 Cochrane review suggested that there is moderate evidence that exercise can prevent recurrences of back pain, although there was conflicting evidence as to its effectiveness as a primary treatment. Based on fewer studies than on exercise or manipulation, a Cochrane systematic review found benefit of massage for patients with subacute and chronic nonspecific low back pain, especially when combined with exercise and education. Research on most conservative treatments for low back pain, including drug therapy, have reported only modest benefits. It remains to be seen whether this is due to the limited effectiveness of the interventions or the heterogeneity of patient populations.

Research continues in an attempt to identify potential responder and nonresponder subgroups currently under the generic label of nonspecific low back pain. Potentially better results can also be linked to combination therapies and interdisciplinary approaches. Neck PainSpinal manipulation was found to be effective for acute and subacute neck pain. Effectiveness was also found for acute whiplash when spinal manipulation is combined with exercise. Spinal manipulation was shown to be effective for chronic neck pain when combined with exercise. However, a new study suggests the efficacy of spinal manipulation alone in patients with associated cervicogenic headache. Massage is also effective for chronic neck pain.

An influential systematic review on this topic was conducted by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain. Extremity ConditionsManipulation of extremity joints is used for a variety of conditions. However, there are fewer trials than for back pain, neck pain, and headaches.

Effectiveness was found for shoulder girdle pain, adhesive capsulitis, lateral epicondylitis, hip and knee osteoarthritis, patellofemoral pain syndrome, and plantar fasciitis. Inconclusive evidence in a favorable direction was observed for rotator cuff pain, shoulder pain, carpal tunnel syndrome, ankle sprains, Morton’s neuroma, hallux limitus, and hallux abductor valgus. The only definitive negative finding was for ankle fracture rehabilitation, while several other forms of post surgical rehabilitation had inconclusive evidence leaning in the negative direction. SafetyManual therapies including spinal manipulation are generally safe. Side effects tend to be benign: minor and self-limiting with short duration (eg, mild postmanipulation soreness).

– Severe complications have been associated with spinal manipulation but are extremely rare. For example, cauda equina syndrome can be as rare as 1 in 100 million following lumbar manipulations. Cassidy et al reviewed approximately 100 million person-years of records to evaluate stroke risk associated with cervical spinal manipulation and medical care.

The authors concluded that the risk was extremely small and there was no excess risk from chiropractic care compared with medical care for neck pain and headaches. They hypothesized that the equivalent risk for chiropractic and medical care suggests that a stroke prodrome can lead to care seeking for these conditions. It is unlikely that manipulation of the neck is causally related to stroke.

Other InterventionsOther interventions commonly employed by the chiropractic profession have a similar evidenced-based foundation. A 2010 Cochrane review suggested that there is moderate evidence that exercise can help prevent recurrences of back pain, although there was conflicting evidence as to its effectiveness as a primary treatment. Based on fewer studies than on exercise or manipulation, a Cochrane systematic review found benefit of massage for patients with subacute and chronic nonspecific low back pain, especially when combined with exercise and education.Research on most conservative treatments for low back pain, including drug therapy, have reported only modest benefits. It remains to be seen whether this is due to the limited effectiveness of the interventions or the heterogeneity of patient populations. Research continues in an attempt to identify potential responder and nonresponder subgroups currently under the generic label of nonspecific low back pain. Potentially better results can also be linked to combination therapies and interdisciplinary approaches. ConclusionEvidence-based practice has made significant inroads into the chiropractic profession by expanding clinical research into interventions commonly employed by chiropractors and by graduating more Evidence-based practice savvy practitioners.

The most common conditions treated by chiropractors are back pain, neck pain, and headaches. The best available evidence supports manipulative therapy as a reasonable option for many of these complaints. Manipulative therapy also holds potential value for the treatment of a variety of extremity conditions.

Chiropractic practice is far broader than spinal manipulation alone, typically including other evidenced-based interventions such as massage, exercise therapy, and activity modification advice. Chiropractic education, with the help of federal grants and partners in established medical schools, is aggressively addressing the need to create more Evidence-based practice savvy graduates.

These efforts will hopefully lead to improved patient outcomes and offer a common language and perspective to facilitate greater interprofessional cooperation.