Journal of Chiropractic Education 2017 (Aug 2) [Epub]
~ FULL TEXT
Barbara A. Mansholt, DC, MS, Stacie A. Salsbury, PhD, RN,
Lance G. Corber, MSITM, and John S. Stites, DC
Palmer College of Chiropractic
1000 Brady Street,
Davenport, IA 52803
OBJECTIVE: Scientific literature applicable to chiropractic practice proliferates in quantity, quality, and source. Chiropractic is a worldwide profession and varies in scope between states or provinces and from country to country. It is logical to consider that the focus and emphasis of chiropractic education varies between programs as well. This original research study endeavored to determine "essential literature" recommended by chiropractic faculty. The purpose of this article is (1) to share our results and (2) to promote discussion and explore means for future collaboration of chiropractic faculty through a worldwide platform.
METHODS: A 2-phase recruitment occurred initially at the institutional level and subsequently at the faculty level. A Web-based survey used qualitative data collection methods to gather bibliographic citations. Descriptive statistics were calculated for demographics, and citation responses were ranked per number of recommendations, grouped into categories, and tabulated per journal source and publication date.
RESULTS: Forty-one chiropractic programs were contacted, resulting in 30 participating chiropractic programs (16 US and 14 international). Forty-five faculty members completed the entire survey, submitting 126 peer-reviewed publications and 25 additional citations. Readings emphasized clinical management of spine pain, the science of spinal manipulation, effectiveness of manual therapies, teaching of chiropractic techniques, outcomes assessments, and professional issues.
CONCLUSION: A systematic approach to surveying educators in international chiropractic institutions was accomplished. The results of the survey provide a list of essential literature for the chiropractic profession. We recommend establishing a chiropractic faculty registry for improved communication and collaboration.
KEYWORDS: Chiropractic; Education; Faculty; Internationality; Research; Survey and Questionnaires
From the Full-Text Article:
The proliferation of the scientific literature poses a challenge to the clinician and educator who desires to be conversant in the research status of a profession. Our study aimed to develop a mechanism to identify and disseminate literature "essential" to the chiropractic profession.  Available research continues to grow at an astounding pace.  Literature affecting the practice of chiropractic is found in a wider variety of resources as research continues to evolve, as recently demonstrated in the American College of Physicians recent clinical guideline for acute, subacute, and chronic low back pain.  The quality of research available also continues to improve through the editorial use of transparency instruments available through the EQUATOR Network, such as CONSORT, STROBE, PRISMA, CARE, STARD, and AGREE,  and quality database resources, such as Cochrane Collaboration  and ClinicalTrials.gov. 
Chiropractic is a worldwide profession. In the United States, many chiropractic programs are private educational institutions and focused predominantly if not solely on the education of chiropractors and chiropractic staff. Internationally, chiropractic programs may exist independently or as part of a larger university system. Chiropractic practice varies in scope between states or provinces and from country to country. It is logical to consider that the focus and emphasis of chiropractic education, philosophy, and research varies between programs as well.
Our current students are the future leaders of our profession; we strive to know how they are molded. What we do not know, however, is whether how or when quality literature disperses through our educational system. Consequently, we wondered, what literature do chiropractic faculty deem "essential" for every chiropractor of which to be aware? The purpose of this study was to survey chiropractic faculty worldwide to determine what literature these faculty deem essential reading for chiropractors and chiropractic students. We share these results not only as a reference of teaching faculty "essential literature" but also to promote discussion and find ways for future collaboration of chiropractic faculty through a worldwide platform.
We conducted an online, descriptive survey to understand what chiropractic program faculty consider to be essential reading for the chiropractic profession. The human protections administrator for Palmer College of Chiropractic determined that this study was exempt per 45 CFR 46, IRB Assurance # X2014-10-17-M. The survey was conducted from March through May 2015.
Participant recruitment occurred on 2 levels: chiropractic
educational institutions and individual faculty members
(Figure 1). We first obtained a list of international and US (n=41) chiropractic programs and their contact information
from the World Federation of Chiropractic (WFC) (http://www.wfc.org). The detailed list included accreditation
agency, country, school, department (if applicable),
physical address, phone, fax, and general e-mail address,
as well as a contact name with their professional
designation, job title, and phone number, fax, and e-mail
address. We e-mailed the designated representative from
each chiropractic program requesting a procedure to
acquire e-mail addresses for all faculty members in their
program; 21 programs replied to this e-mail request.
Personalized follow-up by phone call was necessary to
determine appropriate channels for other institutions (n=4). Several lists (n=5) were obtained via hand retrieval of
faculty listings from a program website. Human resources
departments were also used as a source for obtaining email
contact information. In total, 30 of 41 chiropractic
institutions participated in this study, with 11 chiropractic
educational institutions (1 US, 10 international) not
responding to requests for information. In addition to
direct and indirect recruitment of chiropractic faculty, we
also introduced the survey to prospective respondents via
verbal announcements and handouts at the 2015 Association
of Chiropractic Colleges Research Agenda Conference.
Participant recruitment from
chiropractic educational institutions
and individual faculty members.
Survey Development and Implementation
We developed a Web-based survey in ASP.NET v4.0 in
C# and Structured Query Language (SQL) using Microsoft
Visual Studio 2010 (Microsoft Corporation, Redmond,
WA). All data were stored on an internal Microsoft
SQL Server 2014. The survey was pretested among
chiropractic faculty at our home institution for clarity,
ease of use, and content validity.
The survey was launched in March 2015. Recipients
received a survey link, pass code, and cover letter with a
short explanation regarding the purpose and methods of
the study via e-mail. Recipients received an e-mail and link
either directly from our Web page/server (direct recipients)
or from an individual designated from the program
responsible for survey dissemination (indirect recipients).
Direct recipients received up to 4 automated reminder
messages, depending on their response status within the
software. Institutional contacts for indirect recipients
received up to 3 prompts to disseminate reminders to
The survey used qualitative data collection methods.
Respondents listed the author, title, journal, and year of an
article the respondent considered essential reading for
chiropractors and chiropractic students and included a
short statement indicating why the recommended article
was important. Demographic data collected included
respondents’ age, gender, hours per week reading professional
literature, years of teaching experience, chiropractic
program affiliation, primary assignment (administration,
classroom, clinical, research, or other), full-time or parttime
status, whether a chiropractor or not (if yes,
chiropractic program of training), highest degree achieved,
and clinical practice status.
Descriptive statistics were calculated for demographics
using SAS v9.4 (SAS Institute Inc, Cary, NC). Citations
were ranked per number of recommendations, with the
submission results divided into 2 categories: peer-reviewed
and non–peer-reviewed publications. Further, submissions
were tabulated per journal source and publication date.
We established a method of distribution with 16 of the
17 US chiropractic programs: 5 responded to the initial email
contact, 1 responded to a follow-up e-mail contact, 4
responded after contacting an individual known personally
by 1 of the authors, 5 program faculty lists were obtained
via hand retrieval from a program website, and 1 list was
retrieved by contacting the program’s human resources
department. Of the US programs, 6 programs did not
share faculty e-mail lists but agreed to distribute the survey
via an e-mail to faculty members on our behalf. Five
programs shared complete faculty e-mail lists. We manually
retrieved e-mail lists from the websites of 5 additional
US programs due to an absence of response after multiple
attempts and approaches. One program was unresponsive
to multiple e-mail requests to direct individuals, general
Web inquiry, and voice mails left at human resources.
We established a method of distribution with 14 of 24
programs outside the United States: 9 responded to the
initial email inquiry, 2 responded to follow-up inquiries,
and 2 responded to inquiries submitted via Web inquiry or
program website. Of those, 5 chiropractic program faculty
received direct e-mails, while 9 programs agreed to forward
the survey invitation to their faculty. The 11 chiropractic
programs that did not participate were unresponsive to at
least 2 e-mail requests to direct individuals as well as general Web inquiry. E-mails were primarily sent in
English but also included duplicate text converted via
Google Translate when appropriate. The authors chose
not to attempt to communicate with human resource
departments via phone in some cases due to time zone
differences and potential language barriers.
The survey was e-mailed directly to 713 chiropractic
program faculty members (108 international in 5 programs
and 605 US in 10 programs) and indirectly to 14 programs
worldwide (6 US and 9 international). Figure 2 shows a
map of chiropractic program distribution worldwide.
Global map of
chiropractic education institutions.
While 173 respondents completed the welcome screen
and 24 declined participation, only 45 respondents
completed the entire survey through the demographic
information section; 47 respondents submitted articles.
The response rate is not possible to compute due to the
unknown distribution number, but we estimate that it is
below 5%. The mean age of respondents was 50.2 (SD ¼ 9.8) years, with the majority female (n=30) and
chiropractors (n=34). Slightly over half were full-time
(n=24), with the average time teaching in a chiropractic
program at 12.97 (SD=10.6) years. Thirty reported
formal training in an evidence-based practice within the
past 5 years and spent an average of 7.2 (SD=3.36) hours
per week reading professional literature. Most respondents
were involved in classroom instruction of clinical sciences
(n=16) or research (n=13), with most nonengaged in
clinical practice (n=28). Table 1 presents the remaining
demographic information for the sample.
Table 1 - Respondent Demographics of the Chiropractic Faculty Survey|
Respondents submitted a mean (SD, range) of 4.5 (2.5, 1–10) articles. One hundred and twenty-six peer-reviewed
publications were submitted as essential literature for the
chiropractic profession. Twenty-five submissions were
non–peer reviewed in nature, 19 of which were published
textbooks. Recommended articles were published in the
Journal of Manipulative and Physiological Therapeutics (n=30), Spine (n=14), The Spine Journal (n=9), Chiropractic
and Manual Therapy (n=8), Journal of the Canadian
Chiropractic Association (n=7), and a variety of other
chiropractic, manual/physical therapy, and internal medicine
journals. Publication years ranged from 1979 to 2015;
most publication dates fell in the 2006–2010 (n=38) and
2011–2015 (n=63) ranges.
Table 2 reports the 126 peer-reviewed submissions.
Citations are listed first by the number of recommendations
by survey respondents and then alphabetically by
title and author/citation. A quotation from the recommending
respondents is provided demonstrating the
importance of the article. Articles highlighted in gray are
available currently on the WFC Suggested Reading List for
Chiropractic (accessed May 18, 2017).
Table 3 reports the 25 non–peer-reviewed submissions,
listed first by number of recommendations and then alphabetically by title and author/publisher or source, also
with a quotation from the recommending respondent.
Literature With Multiple Recommendations
Eighteen peer-reviewed articles and 1 textbook received
multiple recommendations. An article by Cassidy and
colleagues, "Risk of vertebrobasilar stroke and chiropractic
care: results of a population-based case control and
case-crossover study," received 11 submissions as essential
literature for chiropractors.  Second in ranking was
Bronfort et al,  "Effectiveness of manual therapies: the
UK evidence report." Five articles received 3 recommendations:
"A theoretical model for the development of a
diagnosis-based clinical decision rule for the management
of patients with spinal pain" (Murphy ), "Clinical
effectiveness of manual therapy for the management of
musculoskeletal and non-musculoskeletal conditions: a
systematic review and update of the UK evidence report"
(Clar et al ), "Diagnosis and treatment of low back pain:
a joint clinical practice guideline from the American
College of Physicians and the American Pain Society"
(Chou et a ), "Dose-response and efficacy of spinal
manipulation for care of chronic low back pain: a
randomized controlled trial" (Haas et al ), and "Review
of methods used by chiropractors to determine the site for
applying manipulation" (Triano et al ).
Twelve additional submissions (11 peer-reviewed articles
and 1 book) were recommended twice. Of the articles, 1 was regarding chiropractic and stroke,  5 regarding
basic science, [14-18] and 5 regarding clinical management of
spine pain. [19-23] The textbook submitted twice was that of
Peer-Reviewed Literature With Single Recommendations
The predominance of submissions primarily referenced
clinically applicable topics, including treatment of neck/
back pain/headaches, diagnostic accuracy, specific case
studies, and treatment of certain populations. [21, 25–73] Many
articles considered essential addressed basic science issues,
such as mechanisms, biomechanics, chemical effects, and
other investigations. [29, 74–99] There were several educationally
themed submissions regarding ethics, consensus terminology,
attitudes, and learning techniques. [100–109] Another theme
was a significant amount of clinical decision-making or
guideline-based treatment topics. [70, 110–118] Several submissions
regarded profession-wide issues, including future
direction and the subluxation debate, and others regarded
current state of research and profession-wide policies. [119–127]
Non–Peer-Reviewed Literature With Single Recommendations
Nine textbooks were recommended encompassing
clinical examination, [128, 129] decision making/management, [130–132] or technique/treatment [133–136] of and by chiropractors. Six textbooks were recommended, including
evidence-based clinical practice,  neurobiologic mechanisms,  biomedical ethics,  biochemistry,  a singlevolume
anatomy atlas,  and 2 regarding immunology [142, 143] Five submissions in this category were summaries
or overviews. [144, 145] Three submissions were compilations
available through governmental process or distribution. [146–148]
Comparison of Essential Literature Findings to WFC Suggested Reading List
Articles highlighted in Table 2 identify readings common
to the Essential Literature for Chiropractic: International
Faculty survey and the WFC Suggested Reading List. Forty-five
(36%) of the readings were shared by both lists. Among
the Essential Literature readings not included in the WFC
offerings, many recommendations were for articles that
would guide the thinking of novice chiropractic practitioners.
For example, chiropractic faculty recommended
13 papers on key clinical trials or observational studies on
chiropractic, spinal manipulation, or manual therapy
techniques. [25, 29, 32, 34, 44, 60, 62, 64, 65, 72]
These teachers cited numerous
articles (n=9) on clinical decision making, such as
classification systems, algorithms, or clinical prediction
rules. [9, 19, 42, 51, 70, 102, 110, 111, 149]
Recent systematic reviews, clinical
guidelines, and best practices related to conservative
care of musculoskeletal conditions also garnered many
endorsements (n=9). [37, 39, 47, 109, 114, 115, 118, 150, 151]
suggested articles on
clinical assessment or training methods (n=7),
case studies (n=4),
outcomes assessment (n=3),
and adverse events (n=3).
Other common topics included
those on models or mechanisms of pathology or interventions
(n=14) as well as professional issues or debates (n=11).
Qualitative Comments to the Survey
Some respondents included qualitative comments in
their responses to the survey. Several who declined
participation stated they were not chiropractors or that
they taught nonchiropractic courses, such as business. This
response contrasted with the survey invitation, which was
open to all chiropractic program faculty regardless of their
training as chiropractors or the types of classes they
taught. Others declined, as they considered themselves
administrators or researchers rather than faculty members.
Several other declines noted that they were not up to date
with chiropractic professional literature, stating, "I can’t
think of 3" or "not something I do regularly." Other
nonrespondents noted that they had declined participation
but received another request or were concerned that there
was not information about how the survey would be used
and that "what is essential today might be outdated next
year." Finally, 1 respondent suggested that the time and
effort of this survey was redundant to a program under
development through the WFC for a suggested reading list
This survey of international chiropractic program
faculty was a follow-up evaluation from a survey of
chiropractic research leaders on the essential literature for
the chiropractic profession. We made a concerted effort to
reach faculty members in all chiropractic educational
programs (n=41) listed on the WFC Web page; however,
only 47 respondents from 16 chiropractic programs
submitted citations. While the estimated response rate
(5%) was disappointing, and much lower than is typical
of surveys of chiropractors,  those who participated
provided thoughtful responses, resulting in a lengthier list
than our previous survey.  The greater response rate from
female faculty is unexpected. We suspect that chiropractic
faculty worldwide is not represented by more females than
males — particularly a 3:1 ratio — although these statistics
are not readily known. An online study of faculty in 2008
showed a response rate of females 12% higher than
males.  Although we cannot speculate regarding the
percentage of respondents, this is an interesting correlation.
Note also that respondents are primarily from "classroom: clinical sciences" and "research."
The results of the survey provide a useful resource for
clinicians, educators, and students and provide a list for
essential reading, and should be considered a complement
to the WFC Suggested Reading List for Chiropractic, an
online resource inspired by our initial survey of Essential
Literature for the Chiropractic Profession and first
published as this current survey was in its implementation
stage. Essential readings with numerous recommendations
from multiple participants included the management
of low back pain and neck pain, basic science and
biomechanical investigations of spinal manipulation, the
effectiveness of manual therapy interventions, teaching
and application of chiropractic techniques, outcomes
assessment, and professional issues for chiropractic.
Interestingly, our comparison of the Essential Literature
and the WFC Suggested Reading List found important
gaps in topics of interest to chiropractic faculty. Indeed,
64% of Essential Literature articles were not included on
the Reading List, such as those on chiropractic education
or clinical prediction rules. Chiropractic faculty in this
survey also recommended many recent articles not added
to WFC Suggested Reading List (although some may have
been disseminated through the "This Week’s Papers"
function of the website). Reading List curators may bear
our findings in mind when updating articles to ensure that
the offerings are useful not only for readers well versed in
the chiropractic literature who might be seeking new
information but also for students, novice clinicians, and
chiropractic faculty who require access to foundational
Most of the recommended peer-reviewed literature
included studies high in strength of research or generalizability/
applicability (systematic reviews, clinical trials,
consensus panels, and so on). A few lower-level-evidence
pieces (e.g., case studies and case series) were recommended.
Conflict may arise regarding whether lower-level
evidence may be considered "essential." While the
rationale for choosing case studies over other, higher
levels of evidence is not known, some respondents may
consider case reports "essential" due to the uniqueness of
the case or for the lessons they offer chiropractic students
who are learning to recognize common clinical presentations
and diagnose complex health conditions. Chiropractic
faculty members are encouraged to frame case studies
within the context of the level of evidence they provide and
to train students to seek information from systematic
reviews and randomized clinical trials whenever these are
The challenges we encountered while implementing
this survey may be of similar concern for researchers
attempting to conduct studies with chiropractic faculty
both in the United States and internationally. We
discovered that there is no established, reliable, and
current mechanism for communicating with faculty
members across chiropractic programs. The WFC was
efficient and responsive in sharing contact information.
However, we had difficulty reaching several institutions
either because the contact was not current or because the
school officials did not respond to our requests for
information. When chiropractic institutions did not reply
to our requests, we attempted to gather faculty contact
information directly from the educational institution’s
website. However, the chiropractor faculty and departments
at some educational institutions were not identifiable
on the designated website. While this may be
understandable in some instances, we found some
nonresponse (to phone calls or e-mails) somewhat
unexpected from an academic institution. Of more
concern is that prospective and current chiropractic
students may not have access to up-to-date background
or contact information about their faculty members, nor
is the composition of the faculty at some chiropractic
institutions transparent to those outside their organizations.
While we spent considerable time and thought developing
and testing our Web mechanism for data entry and
ease of use, we strive to clarify the extensive work that was
necessary to compile the list of faculty. The WFC was
efficient in responding to our list of international
chiropractic programs, which included contact information
and multiple names. The Association for Chiropractic
Colleges (ACC) is another resource for information and
collaboration. Membership in both organizations (1 by
individual and 1 by institution) does come with a fee.
Involvement is either on an administrative level or by
incurring substantial cost in attending conferences. Further,
membership in such chiropractic associations may be
closed to faculty members who are nonchiropractors, as
were 20% of our survey respondents. We are aware of only
1 other resource for connecting faculty through a listserv
of members through the American Chiropractic Association
(ACA), although the European Chiropractors’ Union
(ECU) also appears to have that capacity.154 To our
knowledge, the ACA list is not widely used, and we were
unable to ascertain if the ECU maintains a faculty listserv
by a review of their website.
In our information age, should we be able to easily form
a chiropractic faculty association? Should this be a subset
of the WFC? Whether through the rigors of existing
organizational structure or through a more informal social
media prospect, this seems a viable and beneficial option.
While we are no longer interested in pursuing a compilation
of essential literature, a grassroots platform (as well as
a vetting mechanism for its use) would surely provide for a
low-cost, feasible mechanism for establishing communication,
fostering collaborations, and conducting research
with chiropractic faculty worldwide.
The response rate to this survey was poor. While the
acquisition of faculty contact information was favorable
for some chiropractic programs, it was very challenging to
obtain cooperation and/or responses from many others.
While we could contact most of the US chiropractic
programs, many international chiropractic programs did
not reply to our requests for information. Therefore, we
are not able to make a comparison of readings lists
provided by faculty from different geographic regions, as
any conclusions we might make based on such an
underrepresentative analysis would be spurious at best.
A systematic approach to surveying educators in all international chiropractic institutions was accomplished. The results of this survey provide a cursory list of essential literature for the chiropractic profession. An interesting follow-up or related study would be an examination of the scientific literature used in chiropractic program syllabi. We recommend establishment of a chiropractic faculty registry for ease of communication and collaboration. This could be done under a current established organization, such as the WFC, or alternatively as an international entity affiliated with the ACC.
The authors wish to acknowledge the Palmer College of
Chiropractic and the Palmer Center for Chiropractic
Research for supporting the human and technical resources
allocated to this project.
FUNDING AND CONFLICTS OF INTEREST
No conflicts of interest and no disclaimers to declare.
Although Palmer College of Chiropractic supported this
research efforts indirectly, no specific funding was received
or requested to support this study.
About the Authors
Barbara Mansholt is an associate professor in the clinic at
Palmer College of Chiropractic (1000 Brady Street, Davenport,
IA 52803; firstname.lastname@example.org). Stacie Salsbury is
an assistant professor at the Palmer Center for Chiropractic
Research, Palmer College of Chiropractic (741 Brady Street,
Davenport, IA 52803; email@example.com). Lance
Corber is the data core manager in the office of data
management and biostatistics at Palmer Center for Chiropractic
Research, Palmer College of Chiropractic (741 Brady Street,
Davenport, IA 52803; firstname.lastname@example.org). John Stites is
a professor and director of community clinics with Palmer
College of Chiropractic (2001 52nd Avenue, Moline, IL 61265;
email@example.com). Address correspondence to Barbara
Mansholt, 1000 Brady Street, Davenport, IA 52803; barbara.
firstname.lastname@example.org. This article was received March 7,
2017, revised May 24, 2017, and accepted June 18, 2017.
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