What is Chiropractic?

Transcription

1 What is? today is one of the largest primary-contact health care professions in Canada with over 5,000 practicing chiropractors. Approximately four and a half million Canadians use the services of a chiropractor each year. 1 is a regulated health profession recognized by statute in all Canadian provinces and American states. The benefits of chiropractic care are well recognized by other health practitioners. In a 1995 survey, 44 per cent of Ontario and Alberta physicians indicated that they refer patients for chiropractic treatment. 2 Drug-free, non-invasive health care adjustment is a drug-free, non-invasive manual procedure which utilizes the highly-refined skills developed during four intensive years of chiropractic education. Chiropractors assess disorders related to the spine, nervous system, and joints of the extremities, and provide diagnosis, treatment and prevention of those disorders. The primary goal of chiropractic adjustment, also referred to as manipulation, is to treat areas of decreased movement in the joints of the body, particularly the spine, which can create a reaction in surrounding tissues (ligaments, muscles and nerves) resulting in pain, dysfunction and muscular spasm. Chiropractors are also trained to prescribe therapeutic exercise and other non-invasive therapies including dietary counseling. Adjustment is a highly controlled procedure which rarely causes discomfort. The chiropractor adapts the procedure to meet the specific needs of each patient. Patients often note positive changes in their symptoms immediately following treatment. The vast majority of patients who seek chiropractic care do so for complaints of the musculoskeletal system, most often for conditions affecting the spine. 3 Scientific study of spinal adjustment has clearly demonstrated that chiropractic treatment improves function and is effective for common conditions such as headache, and neck and back pain. 4 Between 86 and 96 per cent of all visits to chiropractors are for these or similar conditions. 5 Governments and legislative bodies across Canada and around the world have conducted extensive reviews of the chiropractic profession and have consistently endorsed chiropractic services. 6 Primary & complementary care What is? 1 of 2 In many cases, such as lower back pain, chiropractic care may be the primary method of treatment. Where other medical conditions exist, chiropractic care may complement or support medical treatment by relieving the musculoskeletal aspects of discomfort associated with the condition. care may also be palliative, providing symptomatic relief to patients with chronic conditions. By treating the musculoskeletal elements of such disorders, chiropractic treatment improves the general well-being of the patient. In this regard,

2 Canada s chiropractors frequently provide complementary care as one element of a patient s overall treatment program. For example, the Canadian Memorial College is a leader in working with other health care providers and offers complementary care at CMCC operated chiropractic clinics in Sherbourne Health Centre, South Riverdale Community Health Centre, Muki Baum Clinics for dually-challenged children and adults, Anishnawbe Health Toronto, and St. John's Rehabilitation Hospital. Regulation & standards is regulated by provincial statute in all provinces. For example, in Ontario, chiropractic has been governed by statute since Currently, it is regulated by the Act (1991) which is administered by the College of Chiropractors of Ontario created in accordance with the Regulated Health Professions Act (RHPA)(1991). Chiropractors along with medical doctors, dentists, psychologists, and optometrists have the legislated right and obligation to communicate a diagnosis and to use the title doctor. The College of Chiropractors of Ontario, like the colleges in each of the other provinces, is established by legislation in the same manner, and with the same structure and similar regulations, as the regulatory bodies for other health professions. It is responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency. November 2001 What is? 2 of 2 1 Use of Alternative Health Care Practitioners by Canadians, Miller W, Canadian Journal of Public Health, 88(3):154-58, Alternative Medicine and General Practitioners: Opinions and Behaviours, Vernoef MJ, Sutherland LR, Canadian Family Physician, 41: , Chiropractors: Do They Help?, Kelner M, Hall O, Coulter I, Toronto, Fitzhenry & Whiteside, Demographic and Clinical Characteristics of Patients: A five year study of patients treated at the Canadian Memorial College, Waalen DP, White TP, Waalen JK, Journal of the Canadian Association, 38(2):75-82, Canadian Resources Databank: A Profile of Canadian Chiropractors, Kopansky-Giles D, Papadopoulos C, Journal of the Canadian Association, 41(3): , See appendix of research references. 5 Chiropractors: Do They Help?, Kelner M, Hall O, Coulter I, Toronto, Fitzhenry & Whiteside, Demographic and Clinical Characteristics of Patients: A five year study of patients treated at the Canadian Memorial College, Waalen DP, White TP, Waalen JK, Journal of the Canadian Association, 38(2):75-82, Canadian Resources Databank: A Profile of Canadian Chiropractors, Kopansky-Giles D, Papadopoulos C, Journal of the Canadian Association, 41(3): , The Effectiveness and Cost-effectiveness of Management of Low-Back Pain, Manga P, Angus D, Papadopoulos C, Swan W, Commissioned by the OCA. Funded by the Ontario Ministry of Health, Services Review, An Internal Review, Wells et al. Commissioned by the Ontario Ministry of Health, in the United States: Training, Practice and Research, U.S. Department of Health and Human Services, AHCPR Research Report, Dec in New Zealand, Report of the Commission of Inquiry, Hasselberg PD, Government Printer, Wellington, Medicare Benefits Review Committee, Thompson CJ, Commonwealth Government Printer, Australia, 1986 Legitimization for Vissa Kiropraktorer, Commission on Alternative Medicine, SOU, 1987.

3 Education In Canada, chiropractors are educated through two programs offered at the Canadian Memorial College (CMCC) in Toronto, and at l Université du Québec à Trois-Rivières (UQTR). Both programs are fully accredited by the Council on Education of Canada (CCEC) which has adopted standards similar to those of the Council on Education in the United States which is, in turn, recognized by the United States Department of Education. Seven years university-level education students undergo a rigorous course of study similar to that of other health care professionals. Entrance requirements are also similar. Students are required to complete a minimum of three years of university before they are eligible for admission to the CMCC accredited program. In fact, over 80 per cent of students entering the CMCC program have completed a baccalaureate degree. The CMCC program requires four years of full-time study, including a year-long internship in the College s clinics. In Quebec, the UQTR has a five-year program following graduation from CÉGEP. Multi-disciplinary faculty In addition to the academic program, chiropractic education requires hands-on clinical experience under the direct supervision of highly-qualified chiropractic faculty. This experience includes clinical assessment, diagnosis, treatment, and referral protocols. The faculty at both CMCC and UQTR have diverse backgrounds and offer students a wide range of expertise. Faculty come from such disciplines as biological sciences, pathology, medicine and psychology, as well as chiropractic. Both the CMCC and the UQTR programs include courses in anatomy, biochemistry, physiology, neurology, embryology, principles of chiropractic, radiology, immunology, microbiology, pathology, nutrition, and clinical sciences specifically relating to diagnosis. In particular, chiropractors receive training in radiology which covers a range of topics from radiation biophysics and protection to clinical x-ray interpretation and diagnosis. Radiology training consists of more than 360 contact hours followed by application during clinical internship. Education 1 of 2

4 Nine universitybased programs Outside of North America, there are eleven chiropractic education programs, nine of which are university-based. 1 Here in Canada, the program at UQTR is within the publicly-funded l Université du Québec system and is the first and only French-language chiropractic program within a university. CMCC and UQTR have also developed relationships both formal and informal with other universities in Canada. For example, faculty and students of CMCC are currently conducting research with fellow scientists at the University of Calgary, University of Toronto and McMaster University. UQTR has collaborations with l Université du Québec à Montréal and Laval University. November 2001 Education 2 of 2 1 University of Glamorgan, South Wales; Anglo-European College at University of Portsmouth, England; University of Surrey, Guildford, England; University of Southern Denmark, Odense; Macquarie University, Sydney, Australia; Royal Melbourne Institute of Technology University, Australia; Technikon Natal, Durban, South Africa; Feeval Central University, Brazil; Technikon Witwatersrand, Johannesburg, South Africa.

5 Research-Based Health Care The history and development of chiropractic, in many ways, mirrors the advance of medical understanding over the past century. During the late 1800 s, the concept of "spinal irritation" was popular in medical circles and the practice of chiropractic was consistent with many aspects of scientific thought at the time. These theories seem quaint today, but at the time, the sophisticated workings of the human nervous system and the spinal cord which the bones of the spine protect were barely known and many branches of medicine were searching for theories to explain how the human body worked. As science advanced, so did understanding of the neurological principles which underlie the effectiveness of chiropractic treatment. Today, these principles form the foundation of chiropractic education. Evidence-based health care has undergone considerable scrutiny from individuals and organizations within the health care and scientific communities, as well as from chiropractors themselves. This scrutiny has been welcomed and embraced by the profession and has resulted in a significant body of evidence around the efficacy of chiropractic care. For example, in the area of neck pain and low back pain alone, more than 44 studies have been conducted assessing the efficacy and safety of spinal adjustment. 1 A leader in chiropractic research The Canadian Memorial College (CMCC) has been a leader in chiropractic research for more than five decades. The College has dedicated itself to the development of an ongoing, productive research program. Faculty have been successful in obtaining research grants from funding agencies and have published extensively in peer-reviewed and refereed chiropractic journals, as well as in multi-disciplinary journals such as the British Medical Journal, Spine, Annals of Internal Medicine, Pain, the Lancet, and The New England Journal of Medicine. Over the years, CMCC has developed relationships with faculty in other academic institutions in North America. Research collaborations have taken place with faculty from the University of Toronto, University of Waterloo, McMaster University, University of Western Ontario, Institute for Work and Health, St. Michael s Hospital, Sunnybrook and Women s College Health Sciences Centre, University of Calgary, University of Saskatchewan, The Texas Back Institute, and St. Joseph s Hospital, Hamilton. Research-Based Health Care 1 of 2 In 1996, CMCC partnered with the University of Waterloo to establish Canada s first chiropractic research clinic within a university.

6 Headache study Colic and asthma research Headache study In 1999, CMCC received a three-year, $1 million grant from the Ontario Ministry of Health and Long-Term Care to study chiropractic and medical treatments for tension headaches. This is a multi-disciplinary project with collaborators from St. Michael s Hospital and McMaster University. Colic and asthma research Most recently, a research report published in 1999 in the Journal of Manipulative and Physiological Therapeutics concluded that "spinal adjustment is effective in relieving infantile colic". 2 The study was a randomized, controlled clinical trial with a blinded observer and compared the effect of chiropractic treatment with a commonly prescribed medication used to relieve infantile colic. Another study, published in The New England Journal of Medicine in 1998, looked at chiropractic as complementary therapy for children with medically-managed asthma. It revealed a trend toward improved quality of life for patients receiving chiropractic treatment based on reduced need for medication and reduced severity of attacks. 3 This is another example of how research continues to inform chiropractic treatment. Canadian Institutes for Health Research partnership In 1998, the then Medical Research Council of Canada (MRC) (now the Canadian Institutes for Health Research or CIHR) and the Canadian Association (CCA) established two Research Fellowships and two Doctoral Research Awards in chiropractic research. The CIHR matches the CCA s contributions dollar for dollar with the mutual goal of improving the health of Canadians through new knowledge generated by research. In the same year, the CIHR partnered with the Canadian Memorial College to offer two Doctoral Research Awards for faculty. In 1999, this partnership was renewed to offer two Research Fellowships and one Doctoral Award to pursue research in specific chiropractic-related areas. In 2000, two Postdoctoral Research Fellowships were awarded. Ongoing research will no doubt further expand knowledge of how the spine, and the neural pathways which it protects, affects health. November 2001 Research-Based Health Care 2 of 2 1 See appendix of research references. 2 The Short-Term Effect of Spinal Manipulation in the Treatment of Infantile Colic, Wiber JMM et al, Journal of Manipulative and Physiological Therapeutics, Vol. 22, No. 8, October A Comparison of Active and Simulated Manipulation as Adjunctive Treatment for Childhood Asthma, Balon J et al, The New England Journal of Medicine, Vol. 339, No. 15, October 1998.

7 and Safety is recognized as one of the safest, drug-free, non-invasive treatments available for headache, and neck and back pain. During the last 25 years there have been six formal government studies of chiropractic, all of which have found the profession to be both safe and effective. 1 Based on the results of more than 44 studies into the safety and efficacy of chiropractic treatment, no other profession, including medicine, can demonstrate greater effectiveness or a better safety record for the treatment of spinal pain syndromes. Safe and effective The risk of stroke from adjustment of the upper neck is very small. Published reports to date put the risk at between one or two out of one million treatments with the risk of serious consequences being even less likely. 2 Most recently, a study published in the Canadian Medical Association Journal based on the most factual data available, puts the risk at 1 in 5 million. 3 Another recent study, conducted by the Institute for Clinical Evaluative Studies, concluded that stroke associated with neck adjustment is so rare that it is difficult to calculate an accurate risk ratio. 4 All of the published studies to date agree that the risk is extremely rare, much lower than for many very common health treatments. In fact, strokes may occur from normal everyday activities such as cradling a phone between your ear and shoulder during a prolonged conversation. 5 Strokes have also been associated with simple activities such as having one s hair washed at a beauty parlour, dental procedures, painting a ceiling, and turning one s head while driving. 6 Other likely treatments for head, neck and back pain carry a notably higher risk. For example: The risk of gastrointestinal bleeding caused by taking common pain relievers, such as ASA over an extended period, is 400 times greater than the risk of damage from neck adjustment. 7 Serious neurological complications from cervical spine surgery are more than 15,000 per million, and the mortality rate is almost 7,000 per million. 8 Attention has also been directed to neck adjustment by Dr. John Norris of the Canadian Stroke Consortium. His survey-style study, which is preliminary, and has yet to be published or peer-reviewed, does not provide sufficient data to draw any conclusions about the relationship between neck adjustment and stroke. Its conclusions are speculative at this point. However, the profession welcomes any research that may contribute to a better understanding of the relationship between neck adjustment and stroke. and Safety 1 of 3

8 Informed consent The chiropractor makes a diagnosis by taking a thorough health history and performing a physical examination. After determining any contraindications to treatment, an appropriate plan of care is developed. Prior to starting treatment, all health professionals are required by law to obtain informed consent to treatment from their patients. Health consumers must receive adequate and accurate information to assist them in evaluating their health care choices, and in balancing the relative risks of treatment options with the benefits. The chiropractic profession has been a leader in obtaining informed consent. Ongoing research researchers continue to be actively involved in studying the benefits and risks of manipulation in the treatment of neck and back pain. Faculty from the Canadian Memorial College have played a leadership role in this research through participation in clinical trials and literature reviews. Currently a large-scale, multi-disciplinary trial is underway to assess the efficacy of different types of treatment, including chiropractic care, for managing tension-type headache. In addition, the profession has published papers reviewing the risks and complications of neck adjustment. The chiropractic profession continues to conduct research that will ensure that care is provided as effectively and safely as possible. November 2001 and Safety 2 of 3

9 1 in the United States: Training, Practice and Research, U.S. Department of Health and Human Services, AHCPR Research Report, Dec in New Zealand, Report of the Commission of Inquiry, Hasselberg PD, Government Printer, Wellington, Medicare Benefits Review Committee, Thompson CJ, Commonwealth Government Printer, Australia, 1986 Legitimization for Vissa Kiropraktorer, Commission on Alternative Medicine, SOU, The Effectiveness and Cost-Effectiveness of Management of Low-Back Pain, Manga P, Angus D, Papadopoulos C, Swan W. Commissioned by the OCA. Funded by the Ontario Ministry of Health, Services Review, An Internal Review, Wells et al. Commissioned by the Ontario Ministry of Health, The Appropriateness of Manipulation and Mobilization of the Cervical Spine: A Systematic Review of Literature, Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG, Spine, 21(15); , Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma and Spinal Manipulation, Haldeman S, Kohlbeck, FJ, McGregor M, Spine, 24(8); , Arterial dissections following cervical manipulation: the chiropractic experience, Haldeman S, Carey P, Townsend M, Papadopoulos, C, Canadian Medical Association Journal, Vol 165, No 7, , Cervical manipulation and risk of stroke, Kapral MK, Bondy SJ, Canadian Medical Association Journal, Vol 165, No 7, , Manipulation and Stroke: A Population-Based Case-Control Study, Rothwell DM, Bondy SJ, Williams JI, Stroke, May Arterial dissections following cervical manipulation: the chiropractic experience, Haldeman S, Carey P, Townsend M, Papadopoulos C, Canadian Medical Association Journal, Vol 165, No 7, , Cervical manipulation and risk of stroke, Kapral MK, Bondy SJ, Canadian Medical Association Journal, Vol 165, No 7, , Manipulation and Stroke: A Population-Based Case-Control Study, Rothwell, DM, Bondy SJ, Williams JI, Stroke, May Carotid Artery Dissection due to Elongated Styloid Process, Zuber, M. Meder JF, Mos JI, Neurology, Nov Beauty Parlour Stroke Syndrome: Report of Five Cases, Weintraub MI, Journal of the American Medical Association, 269: , Abrupt Change in Head Position and Cerebral Infarction, Sherman DG, Hart RG, Easton JD, Stroke, 12:2-6, Vertebral Artery Occlusion Following Hyperextension and Rotation of the Head, Okawara S, Nibbelink D, Stroke, 5:640-42, Cervical Manipulation and Stroke, Eastman JD, Sherman DG, Stroke, 8:594-97, A Risk Assessment of Cervical Manipulation V. NSAIDs for the Treatment of Neck Pain, Dabbs V, Lauretti WJ, Journal of Manipulative and Physiological Therapeutics, 18:530-36, Ibid. and Safety 3 of 3

10 Frequently Asked Questions Does chiropractic treatment require a referral from a MD? No. A patient does not have to be referred. Chiropractors are legislated as primary contact health professionals in every province in Canada. This means that patients can consult them directly. However, chiropractors often work closely with MDs, 44 per cent of whom refer their patients to chiropractors when they believe chiropractic treatment will help alleviate a patient s condition. 1 How is chiropractic adjustment performed? adjustment is a manual procedure which utilizes the highly-refined skills developed during four intensive years of chiropractic education. The chiropractor uses his/her hands to manipulate the joints of the body, particularly the spine, in order to restore or enhance spinal functioning. Adjustment is a highly controlled procedure which rarely causes discomfort. The chiropractor adapts the procedure to meet the specific needs of each patient. Patients often note positive changes in their symptoms immediately following treatment. Can chiropractic treatment cure colds, earaches and other ailments? care cannot "cure" these conditions, but there is evidence to indicate that adjustment may have a beneficial effect on a variety of conditions. More research is needed in these areas before definitive benefits can be claimed. It is important to distinguish between primary treatment and treatment of secondary symptoms. For example, if a patient has an aching ear that is related to the musculoskeletal structures around the ear, and which is not the result of a bacterial infection, then chiropractic treatment may alleviate the pain. This would be considered primary treatment. If there is ear pain caused by a bacterial infection, then chiropractic care is not the primary treatment, but may help alleviate some of the secondary, or referred pain, arising from the musculoskeletal reaction to the ear infection. This would be considered secondary treatment where chiropractic plays a complementary role in the treatment of a condition. Frequently Asked Questions 1 of 3 So, chiropractic care cannot cure a cold or an ear infection, but it may reduce the pain response. Similarly, chiropractic care can be of benefit in relieving musculoskeletal symptoms that are present with diseases such as cancer or AIDS.

11 Is chiropractic adjustment a safe procedure? treatment is a drug-free, non-invasive approach to common musculoskeletal conditions such as neck and back pain. As such, it is a very low risk therapy. In extremely rare situations there is a possibility that adjustment of the upper neck may contribute to a stroke. Is chiropractic treatment appropriate for children? There are many reasons why a child might benefit from chiropractic care. Children are very physically active and experience many types of falls and blows from participating in sports which can cause many symptoms including back and neck pain, and discomfort. care is always adapted to the individual patient. It is highly skilled and, in the case of children, very gentle. While there is a wealth of clinical evidence that musculoskeletal treatment of infants has many positive effects, well-controlled studies are required to verify some of the benefits that are commonly seen in practice. Most recently, a research report published in the Journal of Manipulative and Physiological Therapeutics concluded that spinal adjustment is effective in relieving infantile colic. 2 The study was a randomized, controlled clinical trial with a blinded observer and compared the effect of chiropractic therapy with a commonly prescribed medication used to relieve colic. A study of chiropractic as complementary therapy for children receiving asthma medication revealed a trend toward improved quality of life for patients receiving chiropractic treatment based on reduced need for medication and reduced severity of attacks. 3 This is another example of how research continues to inform chiropractic treatment. Does chiropractic treatment require x-rays? Guidelines have been developed by the chiropractic profession with regard to the use of x-rays as a diagnostic tool. X-rays provide vital information to help determine a diagnosis but they are not required in every case. In fact, at the Canadian Memorial College from 1997 to 1998, fewer than 20 per cent of chiropractic patients received x-rays, and only 6 percent of patients under the age of 16 required an x-ray. Frequently Asked Questions 2 of 3

12 Use of x-ray as a diagnostic tool by chiropractors, and all other health professionals, is governed in Ontario by guidelines as set out by the Healing Arts Radiation Protection Commission (HARP). X-rays can play an important role in diagnosis but are only taken when a need has been determined by a careful case history and physical examination. Chiropractors receive 360 hours of education in radiology covering a full range of topics from protection to x-ray interpretation and diagnosis. Governments in every province have recognized the training and competence of chiropractors to perform x-rays and have granted them this right. Can chiropractic treatment provide a preventative function? Clinical experience suggests that individuals with chronic conditions such as osteoarthritis or recurrent neck pain, back pain or headaches experience less frequent and less severe symptoms when under regular chiropractic care. This also applies to individuals in highly stressful situations and those who experience repetitive physical and postural strain from their daily activities. Whether ongoing chiropractic treatment can prevent back pain from occurring in the first place, or prevent a previous condition from re-occurring, requires further study. November 2001 Frequently Asked Questions 3 of 3 1 Alternative Medicine and General Practitioners: Opinions and Behaviours, Vernoef MJ, Sutherland LR, Canadian Family Physician, 41: , The Short-Term Effect of Spinal Manipulation in the Treatment of Infantile Colic, Wiberg JMM et al, Journal of Manipulative and Physiological Therapeutics, Vol. 22, No. 8, October A Comparison of Active and Simulated Manipulation as Adjunctive Treatment for Childhood Asthma, Balon J et al, The New England Journal of Medicine, Vol. 339, No. 15, October 1998.

13 What Government Reports Say The Effectiveness and Cost-Effectiveness of Management of Low-Back Pain (the Manga Report), 1 commissioned by the Ontario Ministry of Health in 1993, represents a thorough analysis of the scientific literature on low back pain. The report was prepared by health economists at the University of Ottawa including principal author Pran Manga, Director of the Master in Health Administration program at the university. The report reached the following conclusions: Spinal adjustment applied by chiropractors is more effective than alternate treatments for lower back pain. There would be significant cost-saving to the health care system if more management of lower back pain was transferred from physicians to chiropractors. Workers Compensation studies report that injured workers diagnosed with lower back pain returned to work sooner when treated by chiropractors than by physicians. The Ontario Services Review (the Wells Report), 2 prepared by a bipartite committee with representatives from the Ontario Ministry of Health and Long-Term Care and the Ontario Association (OCA) in 1994, is the fullest review of chiropractic services ever conducted by the Ministry and the OCA. It provided recommendations on many aspects of the delivery and funding of chiropractic services in Ontario and concluded: On the grounds of effectiveness, safety, patient satisfaction and public acceptance of chiropractic services, particularly in the management of neuro-muskuloskeletal disorders, chiropractic services should continue to be funded by the Ontario Health Insurance Plan. The citizens of Ontario should have improved access to chiropractic services. November 2001 What Government Reports Say 1 of 1 1 The Effectiveness and Cost-effectiveness of Management of Low-Back Pain, Manga P, Angus D, Papadopoulos C, Swan W. Commissioned by the OCA. Funded by the Ontario Ministry of Health, Services Review, An Internal Review. Wells et al. Commissioned by the Ontario Ministry of Health, 1994.

14 Contacts for Additional Information Canadian Association H. James Duncan, B.F.A., C.H.R.P., C.A.E. Executive Director Ontario Association Bruce Squires, M.B.A. Executive Director Canadian Memorial College Jean Moss, D.C., M.B.A. President Canadian Protective Association Greg Dunn, D.C. Chief Operating Officer College of Chiropractors of Ontario Jo-Ann Willson, LLB. Registrar November 2001 Contacts for Additional Information 1 of 1

15 Research References The following is a small sampling of the large volume of research conducted into the practice of chiropractic, its effectiveness, and its safety. Efficacy of Treatment The Appropriateness of Spinal Manipulation for Low Back Pain, Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brooke RH. Commissioned by the RAND research corporation, Document No. R-4025/1-CCR/FCER, Conclusion: Support is consistent for the use of spinal adjustment as a treatment for patients with acute low-back pain and an absence of other signs of lower-limb, nerve-root involvement. Chronic Spinal Pain Syndromes: A Clinical Pilot Trial Comparing Acupuncture, a Nonsteroidal Anti-Inflammatory Drug and Spinal Manipulation, Lynton GF, Muller, R, Journal of Manipulative and Physiological Therapeutics, 22:376-81, Conclusion: Spinal adjustment, if not contraindicated, results in greater improvement than acupuncture and medicine. Randomised Comparison of and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow-up, Meade TW, Dyer S, Browne W, Frank AO, The British Medical Journal, Vol 311, August 5, Conclusion: Those treated by chiropractic derive more benefit and long-term satisfaction than those treated by hospitals. The Effectiveness and Cost-Effectiveness of Management of Low-Back Pain, Manga P, Angus D, Papadopoulos C, Swan W. Commissioned by the OCA. Funded by the Ontario Ministry of Health, Conclusion: On the evidence, particularly the most scientifically valid clinical studies, spinal adjustment applied by chiropractors is shown to be more effective than alternative treatments for LBP [lower back pain]. Many medical therapies are of questionable validity or are clearly inadequate. There is an overwhelming body of evidence indicating that chiropractic management of LBP is more cost-effective than medical management. Services Review, An Internal Review, Wells et al, Commissioned by the Ontario Ministry of Health, Conclusion: On the grounds of effectiveness, safety, patient satisfaction and public acceptance of chiropractic services, particularly in the treatment of musculoskeletal disorders, chiropractic services should continue to be funded by the Ontario Health Insurance Plan. Research References 1 of 5

16 Trunk Exercise Combined with Spinal Manipulative or NSAID Therapy for Chronic Low Back Pain: A Randomized, Observer-Blinded Clinical Trial, Bronfort G, Goldsmith CH, Nelson CF, Boline PD, Anderson AV, Journal of Manipulative and Physiological Therapeutics, Vol 19, No 9, Nov/Dec Conclusion: Each of the three therapeutic regimes was associated with similar and clinically important improvement over time, however, there was an increase in adverse reactions with NSAIDs. Manipulative Therapy Versus Education Programs in Chronic Low Back Pain, Triano JJ, McGregor M, Hondras MA, Brennan PC, Spine, Vol 20, No 8, , Conclusion: Greater improvement was noted in pain and activity tolerance in the adjustment group. Immediate benefit from pain relief continued to accrue after adjustment, even for the last encounter at the end of the 2-week treatment interval. Multicenter Trial of Physiotherapy in the Management of Sciatic Symptoms, Coxhead CE et al, Lancet, 1: , Conclusion: Greater reductions in perceived pain were reported by those in the spinal manipulative therapy (SMT) group. Combinations of SMT and exercise produced the optimal results. Efficacy of Various Forms of Conservative Treatment in Low Back Pain, Postacchini F, et al, Neuro-Orthop, 6:28-35, Conclusion: Spinal manipulative therapy was found to be the superior treatment in acute cases. Spinal Manipulation in the Treatment of Low Back Pain, Kirkaldy-Willis WH, Cassidy JD, Canadian Family Physician, 31: , Conclusion: Strong support for the value of adjustment in the treatment of chronic lumbar facet and sacroiliac syndrome. Research References 2 of 5

17 Additional References Spinal Manipulation for Chronic Low Back Pain: A Review of the Evidence, Vernon, H, Journal of the Canadian Association, 40(3), in the United States: Training, Practice and Research, U.S. Department of Health and Human Services, AHCPR Research Report, Dec in New Zealand, Report of the Commission of Inquiry, Hasselberg PD, Government Printer, Wellington, Medicare Benefits Review Committee, Thompson CJ, Commonwealth Government Printer, Australia and Safety The conclusions from the following references are summarized in the Fact File document titled and Safety. The Appropriateness of Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature, Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG, Spine, 21(15); , Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma and Spinal Manipulation, Haldeman S, Kohlbeck FJ, McGregor M. Spine, 24(8); , Arterial dissections following cervical manipulation: the chiropractic experience, Haldeman S, Carey P, Townsend M, Papadopoulos C, Canadian Medical Association Journal, Vol 165, No 7, , Cervical manipulation and risk of stroke, Kapral MK, Bondy SJ, Canadian Medical Association Journal, Vol 165, No 7, , Manipulation and Stroke: A Population-Based Case-Control Study, Rothwell DM, Bondy SJ, Williams JI, Stroke, May Perspectives: An Overview of Comparative Considerations of Cerebrovascular Accidents, Rome PL, Journal of Australia, Vol. 29, No. 3, September Carotid Artery Dissection Due to Elongated Styloid Process, Zuber M, Mos JI, Neurology, November Beauty Parlour Stroke Syndrome: Report of Five Cases, Weintraub MI, Journal of the American Medical Association, 269: , Research References 3 of 5 Abrupt Change in Head Position and Cerebral Infarction, Sherman DG, Hart RG, Easton JD, Stroke, 12:2-6, 1981.

18 Vertebral Artery Occlusion Following Hyperextension and Rotation of the Head, Okawara S, Nibbelink D, Stroke, 5:640-42, Cervical Manipulation and Stroke, Eastman JD, Sherman DG, Stroke, 8:594-97, A Risk Assessment of Cervical Manipulation v. NSAIDs for the Treatment of Neck Pain, Dabbs V, Lauretti WJ, Journal of Manipulative and Physiological Therapeutics, 18:530-6, Redefining Whiplash and Its Management: Scientific monograph of the Quebec task force on whiplash-associated disorders, Spitzer WO, Skovron ML et al. Spine, 20:85, Conservative Management of Mechanical Neck Pain: A Systematic Overview and Meta-Analysis, Aker PD, Gross AR, et al. The British Medical Journal, 313: , Paediatric The Short-Term Effect of Spinal Manipulation in the Treatment of Infantile Colic: A Randomized, Controlled, Clinical Trial with a Blinded Observer, Wiberg JMM, Nordsteen J, Nilsson N, Journal of Manipulative and Physiological Therapeutics, Vol 22, No 8, October Conclusion: Spinal adjustment is effective in relieving infantile colic. A Comparison of Active and Simulated Manipulation as Adjunctive Treatment for Childhood Asthma, Balon J et al, The New England Journal of Medicine, Vol. 339, No. 15, October Conclusion: Spinal manipulative therapy may contribute to improved quality of life in terms of reduced need for medication and reduced severity of attacks. Musculoskeletal Pain in Primary Paediatric Care: Analysis of 1000 Consecutive General Paediatric Clinic Visits, de Inocenio J, Paediatrics, Vol. 102 No. 6, Dec Conclusion: MSP [musculo-skeletal pain] represents a frequent presenting complaint in general paediatric practice. A new heightened awareness of the frequent occurrence of MSP should be adopted when designing paediatrics continuing medical education and training programs. Back Pain in School Children: A Study Among 1178 Pupils, Troussier B, Davoine P, de Gaudemaris R, Fauconnier J, Phelip X, Scandinavian Journal of Rehabilitative Medicine, 26:143-46, 1994 Research References 4 of 5 The Epidemiology of Low Back Pain in an Adolescent Population, Olsen TL, Anderson RL, Dearwater MS, et al, American Journal of Public Health, 82(4): , 1992

19 Conditions Treated Use of Services from 1985 through 1991 in the United States and Canada, Hurwitz EL, Coulter ID, Adams AH, Genovese B, Shekelle PG. American Journal of Public Health, Vol. 88, No 5, , May Job Analysis of in Canada, Published by the National Board of Examiners, Chiropractors: Do They Help?, Kelner M, Hall O, Coulter I, Fitzhenry & Whiteside, Toronto, Demographic and Clinical Characteristics of Patients: A five year study of patients treated at the Canadian Memorial College, Waalen DP, White TP, Waalen JK, Journal of the Canadian Association, 38(2): 75-82, Canadian Resources Databank: A Profile of Canadian Chiropractors, Kopansky-Giles D, Papadopoulos C, Journal of the Canadian Association, 41(3): , Trends in Alternative Medicine Use in the United States Results of a Follow-up National Survey, Eisenberg DM, Davis RB, Ettner SL, et al. The Journal of the American Medical Association, 280: , Use of Alternative Health Care Practitioners by Canadians, Millar WJ, Canadian Journal of Public Health, May-June November 2001 Research References 5 of 5