01-32 Backspace Oct20-FINAL-WEB

October 2020 Volume 16 Number 2

Newsletter of the European Chiropractors’ Union

What’s new in this issue?

21

The

associations

during the first

wave of Covid-19

24

Reflections

on pandemics

through history

3

The dangers of

isolation

26

Covid-19: How did

the chiropractic

schools of

Europe

cope?

19

Covid-19 and sports

chiropractic

BACKspace www.chiropractic-ecu.org October 2020 1

01-32 Backspace Oct20.indd 1 08/10/2020 19:10

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01-32 backspace Backspace annonce a4.indd Oct20.indd 1 2 26-08-2020 08/10/2020 14:21:41

19:10


President’s message

The dangers of isolation

THERE IS a saying: “You

cannot bless the fruits and

curse the roots.” Understanding

this is more important now than

ever before! For the past 88 years

the ECU has provided the basis

on which a growing number of

respected national chiropractic

associations collaborated,

communicated, exchanged

information and ideas, and

received and provided valuable

support of all kinds to fellow

chiropractors.

The well-established ‘ECU

roots’ have fed the achievement of

political, educational and research

milestones in European nations

that are currently reaping the

fruits of investment in a vigorous

profession. And that is what

we are still successfully doing

nowadays when, for example, the

BACKspace is published

twice a year by the European

Chiropractors’ Union (ECU)

and distributed free to all ECU

members. Opinions in BACKspace

are not necessarily those of the

editor or the ECU, who reserve the

right to edit all contributions. The

ECU accepts no responsibility for

advertising content.

European Chiropractors’ Union,

PO Box 774, Wakefield,

West Yorkshire, WF1 9UE.

United Kingdom

Tel: +44 (0) 7845 761390

Email: info@chiropractic-ecu.org

Website: www.chiropractic-ecu.org

Edited and produced by

Manya McMahon at

Pinpoint Communication Ltd

www.pinpoint-uk.co.uk

info@pinpoint-uk.co.uk

Tel: +44 (0) 1395 269573

Design and print by Full Spectrum

Print Media Ltd, Basildon, Essex.

To advertise in BACKspace, please

contact Paul Roberts:

info@chiropractic-ecu.org

© ECU. All rights reserved. Reproduction

of any part of BACKspace is not allowed

without the written permission of ECU.

ECU provided a European shield

against a malicious attack on the

profession in Spain recently, after

which the Spanish association

went on the offensive and secured

a great win with the abolition of

liability for VAT on chiropractic

care, following on from the

victorious campaign led by the

Belgian Chiropractors’ Union.

The solidarity and stamina the

ECU generates is more relevant to

the needs of our profession than

ever before. The Union has adopted

a newly refreshed strategy designed

by its own members, that provides

answers and tackles the issues of

today. It is a strategy to develop a

profession that provides Accessible,

Affordable, and Appropriate care

for MSK health: ECU AAA.

It is an undeniable fact that

the chiropractic profession is

unevenly developed across Europe.

Some countries (not necessarily

the smallest) have scant or no

chiropractic care. Others (not

necessarily the largest countries)

seem to have it all: a good supply

of chiropractors operating in

a well-regulated environment,

integration into public health

systems, reimbursement of patient

costs, indigenous chiropractic

schools accredited to Europe-wide

standards, rigorous continuing

professional development, vibrant

research and well-established

channels for knowledge transfer.

In short, all the components that

bring public trust and acceptability.

But most countries, unsurprisingly,

are still somewhere along the path.

Wherever they are on a path of

development – and there is more

than one – the rewards of being a

pioneer include being seen to break

new ground and to chart a path

that others can follow; being looked

up to and emulated. But a wellknown

lesson is that staying at the

top is hard, the peloton is trying

to close the gap and it knows that

doing so does not depend entirely

on individual effort. Peloton riders

“If we make the mistake of

cutting ourselves off from one

another, the profession will

start losing battles”

mobilise the support of others

until they can break from the pack.

Meanwhile, the leading riders

risk confusing the feeling of being

ahead with that of invincibility, as

they don’t experience the heat of

the pursuit anymore. So it is with

chiropractic.

If we make the mistake of

cutting ourselves off from one

another, the profession will start

losing battles, perhaps first in

the countries where it is less

developed. But that in turn will

very soon reach the backyard of

the next group of countries, by

which time it will be too late

to react. The good fight for the

profession will have been lost.

This phenomenon known

as the ‘illusion of isolation’ has

been repeated many times in the

history of how humanity develops

and, also, in the history of our

profession. Mature, visionary, and

generous leadership is required to

avoid such mistakes. A respect for

history is required as well, and a

constant reminder that we all were

at some point in the earlier stages of

development. The better positioned

accept a responsibility to help those

less well positioned. Solidarity,

comradeship, and mutual help is

the way progress is made.

The founding fathers of this

profession, pioneers of the past,

were visionaries who realised that

a divided profession would fall.

That is why they founded the

ECU back in 1932. Visionaries

on whose shoulders we stand,

like C Bannister and E Hancock

from the UK, H and J Gillet from

Belgium, T Gade from Denmark,

A Lundh from Norway, and C

Regli from Switzerland, to name

only a few.

Dear colleagues, we are a small

profession in need of many things.

The ECU, inspired by its past,

with a plan based on today’s needs

and with a clear vision for the

future, will keep providing for the

chiropractic profession. We have a

moral obligation to provide for the

future generations of chiropractors

as our forebears provided for us.

We are all accountable for our

actions which will be recorded

in history. Where would the

profession be right now if those

pioneers 88 years ago had chosen

isolation instead of collaboration!

In the immortal words of Dante:

“The hottest places in Hell are

reserved for those who, in times of

great moral crisis, maintain their

neutrality.”

Vasileios Gkolfinopoulos

ECU President

© Øistein Holm Haagensen


4:21:41 01-32 Backspace Oct20.indd 3 08/10/2020 19:10

ECU news

Meet the new

Secretary General

THE ECU Executive Council

is pleased to announce the

appointment of Ann Blackmore

as ECU Secretary General when

Ian Beesley steps down on 30

November. Ann comes to the ECU

after five years as Director of Policy

and Strategy at the Federation

of Ophthalmic and Dispensing

Opticians in the UK and Secretary

of the Public Affairs and Economic

Committee of the European

Council of Optometry and Optics.

Her previous experience includes

having been Head of Media and

Public Affairs at the Electoral

Commission and 13 years at the

National Council for Voluntary

Organisations, latterly as Head of

Campaigns and Communications.

Commenting on her

appointment, ECU President

Vasileios Gkolfinopoulos said: “In

a strong field of candidates, Ann

impressed the selection panel with

her enthusiasm and experience in

what can be achieved when the

nations of Europe pull together in

support of evidence-based health

care. The ECU has come a long

CMTJ joins the elite

THE CHIROPRACTIC and

Manual Therapies Journal

(CMTJ) has, for the first time,

been recognised by Clarivate in

its computation of the impact

factor for scientific journals

which, though controversial, is

often taken to be an indication

of importance.

Jointly owned by the ECU,

Chiropractic Australia, NIKKB

and the Royal College of

Chiropractors, CMTJ joins

350 other journals making the

rankings for the first time (of

which 178 are fully open access).

For 2020 the listings have more

than 12,000 journals from 83

countries across five continents

and 236 research categories in

the sciences and social sciences.

More than 1,600 journals are

fully open access.

CMTJ achieved an impact

score of 1.52 which is an

impressive start and a tribute to

the work of Bruce Walker and

the whole editorial team. The

Impact Factor is calculated by

dividing the number of citations

in the JCR year by the total

number of articles published

in the two previous years. An

Impact Factor of 1.0 means

that, on average, the articles

published one or two years ago

Farewell to Head Office

THE ECU Executive Council

has decided to vacate the Head

Office in Hampton Hill, UK and

move to a virtual administrative

operation as a result of the ongoing

rise in remote working capability,

which has been further accelerated

by the Covid-19 pandemic.

Paul Roberts, ECU Executive

Administrator, was on site on

3 August to oversee the final

departure. As with many things

that appear to be simple, there was

ECU president during the clear-up

way under the discreet guidance

of our Secretary General of the

past five years and I look forward

confidently to continuing that

development with Ann alongside

the ECU leadership.”

Ann herself added: “What

really excites me about this new

opportunity is working with

an organisation that promotes

a distinct European voice in a

worldwide profession engaged in

the fight against a prevalent cause

of misery and economic loss.”

have been cited one time. Bruce

steps down as editor-in-chief

at the end of the year, to be

succeeded by the impressive

double act of Iben Axén and

Simon French. Iben leads the

Norwegian Research Council

(ELIB) and was a co-contributor

to the development of the

acclaimed Nordic Maintenance

Care Programme. Simon is

well known for his work on

knowledge transfer, aimed

at closing the gap between

scientific evidence and clinical

practice.

The race is now on to improve

on the initial impact score.

more complexity to exiting the

office than originally expected, as

he explains: “The office contained

a volume of files, furniture and

accessories that need to be kept in

storage for the short-term, so these

had to be carefully removed and

taken by courier to a nearby safe

storage facility.”

The move passed off very

smoothly and the ECU

ECU website

improvements

PAUL ROBERTS, ECU

Executive Administrator,

has been busy revamping the

ECU website over the past

few months. He looked at the

structure and content of the

existing website and noticed

a number of areas where

improvements could be made.

“It became clear fairly

quickly that some of the

content of the website was very

old and needed updating,”

he explains. “Additionally, the

structure of the site did not

offer viewers easy navigation,

have much visual impact, or

provide text that is easy to

read and digest.”

Working closely with

the ECU’s communications

lead, Manya McMahon, and

the Secretary General, Ian

Beesley, Paul set to work.

“We have simplified the

structure of the website,

reducing the number of tabs

and menus. Each main tab now

includes a more relevant suite

of content. With help from a

number of authors, we have

updated much of the text and

many of the key documents

across the site. There are still

a few areas to be completed,

but the site is now simpler,

more visual and easier to

navigate than before.”

Paul now expects the

updating of the website to

become a regular activity, and

has developed a process to

ensure this happens.

administrative team now operates

on a virtual basis, says Paul:

“With the increased use of

technology, from cloud-based

storage and backup through to

audio and video conferencing

facilities, maintaining an effective

administration operation is just

as effective from remote locations

as it is in an office for many

organisations, including the ECU.”

4 BACKspace www.chiropractic-ecu.org October 2020



ECU news

WHO (Europe) work programme

Member states of the World Health Organization (WHO) globally – and in its European Region

– are committed to implementing three interconnected strategic priorities, set out in the

Organization’s 13th General Programme of Work (GPW 13):

• Moving towards universal health coverage

• Protecting people better against health emergencies

• Ensuring healthy lives and wellbeing for all, at all ages.

Jan Geert Wagenaar, ECU Vice President offers a chiropractic perspective.

THE FOCUS so far has been

primarily on the risk of

dying prematurely from the four

main noncommunicable diseases

(NCDs), which is below 10% in

some countries, but as high as

31% in others.

Noncommunicable – or

chronic – diseases are diseases of

long duration and generally slow

progression. The four main types

of noncommunicable diseases

are cardiovascular diseases (like

heart attacks and stroke), cancer,

chronic respiratory diseases (such

as chronic obstructive pulmonary

disease and asthma) and diabetes.

However, there is a blind spot

in Europe on the prevalence

and impact of musculoskeletal

conditions as the fifth type of noncommunicable

disease.

Musculoskeletal conditions

are typically characterised by

pain (often persistent) and

limitations in mobility, dexterity

and functional ability, reducing

people’s ability to work and

participate in social roles with

associated impacts on mental

wellbeing, and at a broader level

impacts on the prosperity of

communities. MSK problems

account for 50% of work absences

of at least three days in the EU

and 60% of permanent work

incapacity.

The Global Burden of Disease

(GBD) study provides evidence

of the impact of musculoskeletal

conditions, highlighting the

significant disability burden

associated with these conditions.

In the 2017 GBD study,

musculoskeletal conditions were

the highest contributor to global

disability (accounting for 16%

of all years lived with disability),

and lower back pain remained the

single leading cause of disability

since it was first measured in

1990. A more recent paper in

the Lancet (2018) from Jan

Hartvigsen, Rachelle Buchbinder,

Mark Hancock, Nadine Foster,

Christopher Maher, et al,

addressed the issues around the

disorder and called for worldwide

recognition of the disability

associated with it.

In a statement the WHO

summarises some key facts on

musculoskeletal conditions:

• Musculoskeletal conditions

are the leading contributor

to disability worldwide, with

low back pain being the single

leading cause of disability

globally.

• Musculoskeletal conditions and

injuries are not just conditions

of older age; they are prevalent

across the life-course. Between

one in three and one in five

people (including children) live

with a musculoskeletal pain

condition.


significantly limit mobility

and dexterity, leading to early

retirement from work, reduced

accumulated wealth and

reduced ability to participate in

social roles.

• The greatest proportion of

non-cancer persistent pain

conditions is accounted for by

musculoskeletal conditions.

• Highly prevalent among

multi-morbidity health states,

musculoskeletal conditions

are prevalent in one third to

one half of multi-morbidity

presentations, particularly in

older people.


are commonly linked with

depression and increase the risk

of developing other chronic

health conditions.

It is time for Europe to start

taking musculoskeletal conditions,

and their multimorbidity

presentation with the other

noncommunicable diseases,

seriously.

So, coming back to the three

interconnected strategic priorities:

• Moving towards universal

health coverage

• Protecting people better against

health emergencies

• Ensuring healthy lives and

wellbeing for all, at all ages

WHO – Europe should be

paying more attention to the

complexity of the condition

and the contributors to it, such

as psychological, social, and

biophysical factors, and especially

to the problems faced by lowand

middle-income countries.

The persistence of disability and

the economic damage associated

with low back pain, and the fact

that it cannot be separated from

social and economic factors and

personal and cultural beliefs about

back pain, need to be recognised.

WHO - Europe should therefore

be spending more focus and more

money to research the diagnosis,

treatment and prevention of low

back pain.

The chiropractic profession is

well known for its effective noninvasive

treatment of spinal and

musculoskeletal conditions and

avoiding the use of drugs. There

are current inequalities in the

provision of chiropractic health

services in Europe, both in terms

of capacity and accessibility. In

some countries, chiropractic is

provided as part of the national

health service, while in others,

chiropractors are subject to

prosecution for practising

medicine without a licence. This

inequality is not in the public

interest and denies a sizeable

number of European citizens

access to chiropractic care. It must

be a priority for the chiropractic

profession to reduce health care

inequalities.

Czech

Chiropractic

Association

THE RECENTLY formed

Czech Chiropractic

Association has been voted

a member of the ECU. It is

led by Marcin Dochnal, who

graduated from the AECC in

2014 (see 60-second interview

page 31). Contact details are:

info.rootshealth@gmail.com

+420733304524

Urbankova 3364/55

14300 Prague

Czech Republic

Freepik.com



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ECU news

ECU members have a long tradition of

helping each other in times of need

WHEN THE extent and seriousness of the Covid-19 pandemic

began to become clear the Executive Council, by then meeting on

a daily basis, first decided that it would create a serious financial situation

for member associations if the normal Spring dues were collected in

May and shortly afterwards asked the General Council to agree to cancel

the half year fees altogether. [Later in the year the British Chiropractic

New Officer for EAC

SØREN O’NEILL left the

European Academy of

Chiropractic board at the

beginning of September 2020.

He wrote about his tenure

as Director of Professional

Development when handing over

to his successor, Michael Vaarst:

“My experience is that there

are some very dedicated and

ambitious people in the EAC

and ECU and they are doing

important work to further our

profession. It is clear to me that

as a profession we have now

reached a point where we have

to acknowledge that simple onesize-fits-all

political solutions are

unlikely to fit anyone at all – for

that, the profession has simply

become too heterogeneous in

state and ambition. I foresee

that international political work

for our profession will only get

more complex in future. I would

like to have contributed more to

this work, but other obligations

are straining my time and

resources. Recently I have taken

up the reins as acting leader

of the research department

of the Spinecenter, which I

must prioritise. The EAC work

deserves more attention than

I can reasonably afford it and I

have no doubt that Michael will

do a better job than I could.”

The EAC is very grateful for

Søren’s contribution towards

strengthening the Graduate

Education Programme for ECU

member nations in the last

three years.

Michael Vaarst is a

chiropractor in private practice

in Denmark. He graduated

from CMCC in 1991 and did his

Graduate Education Programme

(GEP) at the Nordic Institute

of Chiropractic and Clinical

Biomechanics (NIKKB) in Odense

upon returning from Canada.

His experience in the area

of professional development

has primarily been with GEP in

Denmark and started in 2003,

when he became a member

of the Danish Chiropractic

Association board for GEP. He

became the chairman of the

board in 2008. During the last

few years, he has attended GEP

meetings at ECU level as well

as meetings with the National

Health and Accreditation board

(part of the Danish Health

Ministry). A member of an

advisory board, he has been

involved in giving feedback

to the University of Southern

Denmark (SDU) and has

attended many GEP weekends

with the newly graduated

chiropractors in Denmark.

Association was granted a further waiver of its member fees – those

due in the Autumn – on account of an economic crisis faced by British

chiropractors who had been advised to adopt hygiene protocols that

severely restricted clinic capacity.]

Over recent years the ECU has made financial grants to the profession

in the region of €1.5 million.

Date Country Reason Category (Euros)

May-08 Switzerland Support for Zurich school Education 75,000

Nov-08 Other Support for ProChiropractic Europe (PCE) Sponsorship 45,000

TOTAL 120,000

Nov-09 UK WIOC Education 5,000

Nov-09 Spain RCU Education 22,250

Nov-09 UK AECC Education 22,250

Nov-09 Other WCCS Sponsorship 21,000

Nov-09 Other ECCE annual support Education 35,000

TOTAL 105,500

Nov-10 Norway Research seminar Research 50,000

Nov-10 UK Legal costs Legal 115,000

TOTAL 165,000

May-11 Sweden Meetings with Gothenburg school and Education Ministry Education 9,475

TOTAL 9,475

May-12 France Funding of professorship at Orsay Education 60,000

May-12 UK Learning space at WIOC Education 57,200

May-12 UK BCA Business Seminar Education 14,000

May-12 Norway Creation of research council Research 9,000

May-12 Sweden Creation of research council Research 3,000

May-12 UK Creation of research council Research 20,000

May-12 France Creation of research council Research 9,000

Nov-12 Italy Chiropractic Action Team – Italian earthquake Sponsorship 770

Nov-12 Netherlands Funding for Researcher's position at VU Education 75,000

Nov-12 Other Chiropractic Patients' Federation Europe (CPFE) Sponsorship 5,000

TOTAL 252,970

May-13 Spain Video monitoring system - Barcelona College of Chiropractic Education 35,000

May-13 Other Funding of fellowship of position at WHO Sponsorship 10,000

Oct-13 Netherlands Various Sponsorship 3,765

Nov-13 Other Funding for PCE Sponsorship 10,000

TOTAL 58,765

May-14 Hungary Translation of documents for statulatory regulation Legal 5,000

May-14 UK Upright MRI scanner at AECC Education 30,000

Nov-14

No financial requests received

TOTAL 35,000

May-15 Turkey Legal costs Legal 5,000

May-15 Georgia Tsblisi University Education 5,000

Nov-15 Belgium Funding of a colloquium Sponsorship 5,000

Nov-15 UK BCA Membership drive Marketing 170,000

TOTAL 185,000

May-16 Belgium Formation of research council Research 1,665

May-16 Ireland Formation of research council Research 1,560

May-16 Other WFC participation at WHO (contingent - subsequently Sponsorship 27,000

not req’d)

TOTAL 30,225

May-17

No financial requests received

Nov-17 UK AECC – Resources centre Education 16,750

Nov-17 Other ECCE additional funding Education 8,750

Nov-17 UK Society for Promotion of Chiropractic Education (contingent) Education 25,000

Nov-17 Netherlands VU research position Research 65,000

Nov-17 Spain Support for member's legal fees Legal 3,000

Nov-17 Other WCCS (Europe) meeting in Spain Sponsorship 2,500

TOTAL 121,000

Nov-18 Netherlands Sponsorship of establishment of clinic in Uganda Sponsorship 2,000

Nov-18 CAI Irish radiation directive Legal 1,500

Nov-18 UK McTimoney College – electronic booking system Education 6,000

TOTAL 9,500

Mar-19 Ireland Cover for possible legal action - subsequently not req’d Legal 7,500

Mar-19 Spain Combating pseudo-science allegations Communications 44,700

Mar-19 Norway Socio-economic costs of lbp in Norway Research 40,000

Nov-19 Switzerland Expansion of chiropractic student recruitment Education 107,000

Nov-19 Spain Survey of patients Education 9,600

Nov-19 Belgiu/NL Establishment of joint research institution Research 7,500

Nov-19 Estonia VAT exemption claim Regulation 4,200

TOTAL 220,500

Nov-20 UK Grant to waive BCA Autumn ECU dues Other 145,000

GRAND TOTAL 1,457,935




ECU news

North, East, West or South

– associations are active

Estonia targets

acceptance as Healthcare

Service Providers

LKR opens the door to

new members

DKF joins fight against

health inequality

Austria introduces GLA:D

BACK programme

BCU secures

chiropractic inclusion

in plans to introduce

proportionate

regulation

AEQ secures

chiropractic VAT

exemption

Turkey to challenge an

Administrative Court

judgment against

recognition of the

chiropractic profession

IRELAND

UNITED

KINGDOM

PORTUGAL

ICELAND

FINLAND

NORWAY

SWEDEN

NORTH SEA

ANDORRA

SPAIN

LUXEMBURG

FRANCE

NETHERLANDS

BELGIUM

ESTONIA

BALTIC SEA

LATVIA

DENMARK

LITHUANIA

BELARUS

POLAND

GERMANY

CZECH

REPUBLIC

SLOVAKIA

AUSTRIA

HUNGARY

SWITZERLAND

SLOVENIA

MONACO

ITALY

CROATIA

ROMANIA

BOSNIA AND

HERZEGOVINA

SERBIA

BULGARIA

MONTENEGRO

LIECHENSTEIN

MACEDONIA

ALBANIA

GREECE

MEDITERRANEAN

SEA

MALTA

MOLDOVA

UKRAINE

BLACK SEA

TURKEY

BCA resignation

ON 15 September, the

BCA President wrote to

the ECU President “to give

notice under Article 3 (h) of the

ECU Constitution, on behalf

of the BCA, to resign from the

ECU.” The resignation letter

included claims pertaining to

“deficiencies in ECU governance

arrangements” and ended with

“Conditions for re-joining the

ECU.”

The ECU replied on 16

September acknowledging the

resignation with immediate

effect and fully rejecting the

claims made in the BCA letter,

in a thorough and analytical

fashion. Following the release

of the BCA resignation letter

on 17 September, the ECU has

received numerous requests to

publicly release its response.

The ECU has a policy of not

intervening in the internal

matters of national associations.

In the spirit of good governance

and respect of this policy we

would like to make clear that it

is for the BCA Board to decide

whether to share the ECU letter

with its members. A decision

to release such communication

would greatly enhance

transparency around the issue.

The ECU is proud of its

history and what it and its

members continue to achieve

by supporting and funding

research, transfer of

knowledge through jointly

financing the journal

Chiropractic and Manual

Therapies and the Global

Education Network for

Chiropractic (GEN-C),

assistance to the ECCE

accredited chiropractic schools,

and support for member

associations in their dealings

with national health authorities.

We are also proud of the

democratic, transparent, and

collaborative fashion in which

both our Executive and General

Councils operate. We have

always believed that together the

profession can move mountains

and that national isolationism

serves only to weaken it.



Convention

ECU2020 – The Lockdown Series

WHEN THE Covid-19 virus

closed Europe, and the ECU2020

Convention was cancelled, some of

the scheduled speakers and researchers

generously agreed to record presentations

from lockdown for us to share with you,

as a step towards a brighter future.

We will be releasing one of these

presentations on the ECU app and

website every other Monday from 2

November, to offer you inspiration

and thoughts for a way forward and to

support you in your practice.

You can download the ECU App

from the App Store (IOS) or

https://tinyurl.com/y38cvowq (Android)

Date Speaker Title

2 November 2020 Greg Kawchuk How Big Data is Transforming Chiropractic

16 November 2020 Michael Freeman Medicocausation in Auto Litigation

30 November 2020 Mark Thomas Incident Reporting and Learning Using CPiRLS

14 December 2020 Cecilie K Overås Objectively Measured Physical Behaviour

and Neck and/or LBP

28 December 2020 Casper Nim Pain Sensitivity following SMT for chronic LBP

11 January 2021 Dave Newell The Therapeutic Encounter

25 January 2021 Robert Silverman The Gut-Brain Axis

8 February 2021 Simon Billings Vitamin B12 : An Epidemic of Misdiagnosis

and Missed Diagnoses

22 February 2021 Rikke Krüger Jensen Chiropractic Website Claims about non-MSK

conditions in Denmark

Kristina Boe Dissing MSK pain in Danish schoolchildren aged 8-16

Corrie Myburgh Chiropractors and Elite Danish Football Clubs

8 March 2021 Jamiu Busari United We Stand – Divided We Fall: The need

for greater interprofessional collaboration

22 March 2021 Vasileios Gkolfinopoulos Closing speech

Greg Kawchuk Robert Silverman Casper Nim

Dave Newell Simon Billings Jamiu Busari

ECU 2020 cancellation

On 11 March the World Health Organization (WHO) declared

Covid-19 to be a global pandemic as the number of identified

cases passed 120,000 in over 110 countries. Once a pandemic has

been declared by the WHO this triggers governments to activate

preparedness plans and possibly take emergency procedures to

protect the public, such as more drastic travel and trade restrictions.

EARLY IN the preparations for ECU 2020

– long before the outbreak in Wuhan had

been declared – the Executive Council had asked

its engaged professional conference organiser,

Your Conference Support of Amsterdam (YCS),

to obtain a quote for event insurance. The ECU

had never before taken out event insurance and

initially the EC was minded not to take up the

quote. But after reports began to emerge of a

serious outbreak of a flu-like illness in Wuhan

in China, immediate instructions were given to

YCS and they were able to secure the original

quote shortly before the curtain came down on

new events insurance packages that would cover

cancellation because of Covid-19.

The Eurovision Song Contest 2020, which

was due to be held in Rotterdam one week

before the planned ECU 2020 Convention, was

cancelled on 18 March. On the evening of 23

March the Dutch Prime Minister announced

the tightening of previous restrictions to prevent

the spread of the virus (which were valid until 6

April) with new measures valid until 1 June that

required the immediate cancellation of all public

events with very few exceptions. The following

day the sad decision to cancel ECU 2020 was

announced on ECU media and immediate

action was started to refund attendance fees to

the 309 delegates already registered. With 11

weeks to go, bookings were high and well on

track with the budget for the event, reflecting

the exciting programme put together by Gitte

Tønner and the Netherlands Chiropractors’

Association in the 21st-century Jaarbeurs venue.

By the planned opening day of the convention,

the Executive Council was able to report that over

two-thirds of delegates had already been refunded

in full and the remainder would receive their

CONVENTION 22-24 MAY

UTRECHT THE NETHERLANDS

payments just as soon as administrative information

such as the remaining recipients’ bank accounts

was available. The exercise was completed well

in advance of settlement of the claim against the

event insurance policy, and in due course, the ECU

received over 99% of the unrecoverable convention

costs. It was a timely reminder that, in an

increasingly unsettled world, action to safeguard its

financial position is effort (and money) well spent.

As we go to print, the future of physical

conventions looks highly uncertain, at least in the

short-term. Many organisations are experimenting

with virtual conferences and the ECU is exploring

such options for 2021. But there will undoubtedly

come a time when travel is less onerous and

the urge for fellow professionals to get together

across national boundaries will be irresistible.

The renowned ECU Convention will rise,

phoenix-like, from the ashes of the pandemic.




Research

Valedictory

thoughts

Bruce Walker, editor-inchief

of Chiropractic and

Manual Therapies, requires

little introduction. He steps

down later this year and BACKspace took the

opportunity to seek his valedictory thoughts

Highlights of the past

30 years?

BEING IN full time practice

for 30 years allowed me

to treat approximately 35,000

people and deliver about 100,000

consultations. I hope and trust

that I was able to help the

majority of those people with

their musculoskeletal problems.

I was a relative late-comer to

academia, but during my 15 years

at Murdoch University, I was

fortunate to pass the 100 peerreview

article milestone and have

my work cited over 3,500 times.

I hope that my memory will be

my commitment to chiropractic

via the creation of COCA (now

Chiropractic Australia), the

promotion of evidence-based

practice and the establishment of

Chiropractic & Manual Therapies.

Development of the

Journal?

I started the Journal in 1992 with

a small team of chiropractors and

osteopaths in Australia, and it

later became a fully peer-reviewed

journal. We developed as a joint

venture with the ECU and the

Royal College of Chiropractors,

and later with NIKKB, moving to

online publication in 2005. Our

plan was to achieve MEDLINE

listing and an Impact Factor (IF),

reaching both goals with the initial

IF of 1.5 earlier this year. So far,

the journal has been accessed over

4.6 million times since 2005. I

am confident that under the new

leadership of Iben Axén and Simon

French it will continue progress

with bigger and better things.

Progress towards the

10-point plan you

proposed for the

profession in 2016?

The article detailing the plan was

published in CMT in 2016. I

believe that the plan still holds

true today. Progress has been

agonisingly slow, but I predict

that within 50 years the profession

will be vastly different from today.

There has been a greater shift

towards evidence-based practice.

The most pressing

scientific question

and the next research

landmark?

The most pressing question is

what are the markers that predict

response to spinal manipulation

for spinal pain? Regarding research,

in the 10 years between 2010 and

2019, PUBMED documents 3,276

articles involving chiropractic

compared to 173,000 articles

about physiotherapy. We urgently

need much more high-quality

chiropractic research to boost our

international standing.

Final thoughts?

I encourage all chiropractors

to continue serving the public

and to put their patients first, to

volunteer for the advancement of

the profession, to acknowledge

good practice when they see it

and to call out poor practice when

they witness that. I encourage all

to embrace the three elements

of evidence-based practice, i.e.

best scientific evidence, clinical

expertise and patient values and

circumstances.

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Upcoming Course Start Dates:

Bournemouth, UK,

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Research

Getting to know the European

CARL II researchers

The second cohort of 14 CARL researchers

was appointed in 2019, including five from

Europe. BACKspace has been investigating

what inspires these five individuals to develop

their research and influence the future of

chiropractic.

CARL II European Fellows

Name Based at Research interests Professional hero

Steen

Harsted

University of Southern Denmark.

Department of Sports Science and

Clinical Biomechanics.

Research Unit for Clinical

Biomechanics.

Motion capture and

biomechanics

THE CARL Programme was established in 2016 to identify, nurture

and support emerging researchers focused on chiropractic, helping to

develop and lead a sustainable international chiropractic research culture

able to meet the evidence needs of patients, practitioners and policymakers.

The first 13 CARL Fellows (4 from Europe) completed their four years

on the programme in 2020 having boosted the evidence base and research

capacity in chiropractic with over 20 published articles.

Associate Professor Peter Kent from Curtin University,

Australia.

I find his ability to stay present, mindful, and hearty

while debating complicated, difficult issues incredibly

inspiring.

Amy

Miller

Completing a PhD with

Bournemouth University Visiting

researcher at AECC University

College.

Infant musculoskeletal

health

Joyce Miller (no relation) has been a mentor,

inspiration, and friend since my research spark

was ignited six years ago. She has shown intrepid

dedication to her research area of interest, despite

the challenges this brought. As a mentor, Joyce

is generous and enthusiastic with her time and

knowledge, and she challenges me beyond what I

believed my capabilities to be.

Casper

Nim

SpineCenter of Southern Denmark

and Department of Regional Health

Research, University of Southern

Denmark.

Understanding the

aetiology of low back pain

and spinal manipulation.

Sir Isaac Newton. His creativity, understanding, and

development of physics and mathematics has really

inspired me – especially his three laws of motion.

Testing these out in high school was probably the first

time I truly played around with science.

Luana

Nyirö

Completing a PhD at the Medical

Faculty of the University of Zurich,

Switzerland.

Balgrist University Hospital in Zurich

The mechanisms of spinal

manipulative therapy.

As a researcher, Johannes Kepler. Relying on a

systematic and thorough approach, he was openminded

and confident enough to even overturn the

contemporary model of the solar system.

Cecilie

K.

Øverås

PhD Fellow at Department of Sports

Science and Clinical Biomechanics at

University of Southern Denmark.

Department of Public Health and

Nursing at Norwegian University of

Science and Technology

A focus on prognosis and

prevention of spinal pain

My main supervisor Jan Hartvigsen for everything he

has achieved within academia and the strong position

he has attained and keeps, but also because he’s just

such a nice, wise, insightful person that I really look

up to.

Collaboration and

synergy

The key benefit of participating

in the CARL programme is

collaboration with other chiropractic

researchers across the globe: “The

CARL II cohort is very diverse, and

this diversity presents an incredible

opportunity for development,”

explains Steen. “I am sure this will

reflect positively on the chiropractic

profession in the future.”

Cecilie quotes Helen Keller

to illustrate the benefit of this

collaborative approach: “Alone we

can do so little, together we can

do much more”, and Amy agrees

that synergy is key: “We have the

incredible resource of the three

mentors’ and other 13 fellows’

minds! We each have topicspecific

and methods-specific

knowledge and experience,

so expertise can be found and

utilised very quickly within the

group. This gives us opportunities

for synergistic, collaborative work

on a global scale.”

Additionally, a multidisciplinary

approach and collaboration with

other health care professionals

are crucially important to

these early career researchers:

“The benefits that come from

extended understanding and

relationships with other health

care professionals are substantial,

and most importantly can

improve patient care,” says Amy.

Steen agrees, pointing out that

chiropractors communicate

regularly with medical doctors,

physiotherapists, massage

therapists and psychologists as

part of their daily management of

musculoskeletal issues.

Casper works at the Spine

Center of Southern Denmark

12BACKspace www.chiropractic-ecu.org October 2020



Research

at the University Hospital of

Southern Denmark and is used to

working with multiple professions:

“I believe that collaborating and

learning from interprofessional

partners will give chiropractors the

necessary tools to cement ourselves

as the primary spine care provider

across Europe.” Cecilie too, has

always worked in multidisciplinary

settings, both in clinic and as a

researcher: “I could not think of

working differently. I think it is

a must to be able to both work

with and learn from other health

care professions. For instance, for

persistent LBP multidisciplinary

pain management is

recommended.”

Luana highlights another

advantage to collaboration

on this scale: “My experience

is that in academia, the

professional background is

secondary. Our research group

is a multidisciplinary team of

researchers with backgrounds in

human medicine, physiotherapy,

movement and neuroscience as well

as chiropractic. This multifaceted

background and shared expertise

help us to improve our research

designs, and with that our

knowledge of the musculoskeletal

system and the understanding

of the effects and mechanisms of

chiropractic treatments on it.”

The evidence base for

chiropractic

There has long been a call for

more evidence for chiropractic

effectiveness, which depends on

building research capacity and

leadership, as Cecilie describes:

“There is a lot of research

competence within the CARL

Fellow cohort. Bringing together

this capability will allow for

new collaborations and projects

with publications and research

dissemination that will help

build the evidence base for the

chiropractic profession.”

Casper agrees, pointing out

the importance of “the leadership

we attempt to deliver at our

national organisations, scientific

conferences, social media, etc.” and

expressing the hope that CARL can

inspire more students to become

researchers in the future.

Boosting that research culture

in the profession is something that

both Amy and Cecilie feel should

begin very early in chiropractic

education: “I think the most

important thing is to introduce the

idea and opportunity for research

at the pre-registration stage, within

chiropractic programmes,” says

Amy. “This was how I caught the

research bug!” Cecilie supports

the idea that research is central to

later chiropractic education as well:

“That culture definitely has to start

being built during chiropractic

education and we may have to do

more to ensure that research is a

central part of every chiropractor’s

continuing professional

development. Different countries

may have different systems for

CPD activities, but do they

promote and reward updates on

research over other CPD activities?

GEN-C is a good initiative by the

ECU that I hope chiropractors will

actively use.”

Casper suggests: “Instate models

where some of the patient expenses

or reimbursements are transferred

to research funds. Benefit from

the continuity of having a single

organisation which relies heavily on

research and researchers to make

the appropriate political decisions.

And promote more in-person

access to researchers for students.”

Transferring research

findings to clinical

practice

A crucial, and difficult question

to answer is how we can speed up

the transfer of research findings

to clinical practice. As Casper

highlights, the way scientific

journals are published slows

things down: “The entire structure

surrounding how we currently

publish scientific journals should be

modified and open-access instead

of heavily gated by the services

who finalise the manuscripts. A

more realistic approach would be

to continue the work we do on

sharing research on social media,

have more researchers in political

committees, and enhance the work

of clinical guidelines.”

Luana feels that a lot of research

findings are lost in knowledge

translation, and that more effort is

needed to make implementation

interventions: “Often, clinical

practice and clinical research seem

to be two completely different

worlds. However, research should

not be considered an end in itself:

without clinical practice, there is

no application of research results.

I am convinced that we need more

‘physician-scientists’; to build

bridges for evidence transfer, but

CARL was established and

designed by an international

consortium of senior

researchers at the University

of Alberta, Canada (Professor

Greg Kawchuk), the University

of Southern Denmark and

the Nordic Institute of

Chiropractic and Clinical

Biomechanics (Professor

Jan Hartvigsen), and the

University of Technology

Sydney, Australia (Professor

Jon Adams).

The programme is

generously funded by:

• European Chiropractors’

Union through its research

arm, the European Centre

for Chiropractic Research

Excellence

• Australian Chiropractic

Association

• Parker University

• Forward Thinking

Chiropractic Alliance

• UK Chiropractic Research

Council

• Nordic Institute of

Chiropractic and Clinical

Biomechanics

• Australian Research Centre

in Complementary and

Integrative Medicine

also to identify research questions

relevant for clinical daily practice.”

Cecilie points out that

implementation research is a skill

that some of the CARL Fellows

have experience with, and she

hopes that it can be an important

tool. She also emphasises the

importance of involving clinicians

in research: “It is imperative that

chiropractic education continues

to produce graduates who can deal

with scientific literature. I believe

in involving clinicians in research

to give them ownership and hence

motivate them to implement new

research and practice according to

evidence.”

Steen is fascinated by the

approach taken in the GLA:D Back

group-based patient education

programme, where researchers

created an evidence-based course

and taught it to clinicians: “This

seems to me a very different and

much more impactful approach

to transferring research findings

than going to a conference and

giving a 20-minute talk. I am

also interested in exploring new

media for transferring research

findings. Being a clinician myself,

I understand how important it is

that research findings are delivered

in an easily understandable and

approachable manner.”

Amy agrees that new media show

a way to speed up the adoption

of research findings: “I have really

enjoyed Andreas Eklund’s (CARL

I Fellow) use of video summaries

on social media, with clinical

take-home messages for practice.

I think that we as researchers can

and should continue to be open

and creative in how we get our

research findings out to those with

boots on the ground and hands on

people. Not everyone has the time

or resources to be at every major

conference.”

Research during a

pandemic

The four-year programme for

these researchers has not begun in

the way they would have hoped;



Research

lockdowns and the need for social

distancing have made meetings,

networking and collaborations

much more difficult, if not

impossible, and they had to miss

their first residential in April.

However, they have managed to

find benefits even in this extreme

situation, Steen particularly so:

“I handed in my PhD thesis in

March, ten days after the lockdown

in Denmark. We had to conduct

the defence over Zoom, but it was

actually an excellent experience

with several added benefits. For

one, my international collaborators

could attend the defence session,

and the carbon footprint of the

ordeal was significantly reduced as

one of the examiners was spared a

flight from Australia to Denmark.”

“Covid-19 has forced institutions

to think in a new way and integrate

digital technology in a short time,”

says Cecilie. “But some types of

teamwork, brainstorming and

exchange of ideas work better

when you meet in person, so I

think some potential research

opportunities may have been

shifted slightly forward in time.”

Luana explains that the pandemic

has led to interesting developments

worthy of scientific exploration

within and around the chiropractic

profession: “For example, a

debate arose on social media

whether personal immunity can

be improved or ‘boosted’ through

spinal manipulative therapy. For

me personally, this phenomenon

resulted in my first collaboration

and also publication within CARL

II, when we analysed the Twitter

activity regarding that claim.”

Of course, all the chiropractic

researchers are looking forward to a

time when some kind of normality

will return to their activities, and

they can include participants in

experimental research.

We wish the CARL II

Fellows luck for the rest of their

programme and look forward to

seeing the benefits of their research

as it is integrated into chiropractic

practice over the next few years.

The Nordic maintenance care programme

The Nordic maintenance care programme reduces the number of

days with pain in acute episodes and increases the length of pain free

periods for dysfunctional patients with recurrent and persistent low back

pain – a secondary analysis of a pragmatic randomised controlled trial.

Summary

PATIENTS WITH recurrent

and persistent low back

pain (LBP) reported significantly

fewer days of bothersome pain

when receiving maintenance care

(MC) regardless of symptoms,

compared to those receiving care

only when a relapse occurred. This

was true mainly for patients with

a ‘dysfunctional’ psychological

profile, described as having high

pain severity, marked interference

with everyday life, high affective

distress, low perception of life

control and low activity levels.

In this secondary analysis, we

explored wherein this effect lies

by examining pain trajectories

around a treatment visit.

Clinically, patients experience

more pain leading up to the

visit, and pain relief thereafter.

Patients reported their ‘number

of days with bothersome pain’

weekly with text messages, and

the participating chiropractors

reported the date of each

treatment. A treatment period

was defined as treatment(s) with at

least four weeks since the previous

treatment. The pain trajectory was

examined three weeks before and

three weeks after the initial visit in

a new treatment period.

The MC patients with a

dysfunctional profile reported a

significantly ‘flatter’ pain trajectory;

ECCRE research projects

ECCRE HAS backed 13

research projects since its

research grant was set up in 2016.

Andreas Eklund, one of the

original applicants in 2016, has

completed his research project

Chiropractic Maintenance Care –

cost-utility, psychological factors and

pain trajectories and submitted

his final report. Eklund and his

co-investigators conclude that

Chiropractic Maintenance Care

reduces the number of days of

pain within each LBP episode

among patients classified as

dysfunctional (by the MPI-S

instrument), by limiting the

impact of each new episode,

stabilising the clinical course and

increasing the number of pain-free

weeks. Timing of treatment and

patient selection appear to be key

features when aiming to improve

the effectiveness of MC. Patients

with a predictable clinical pattern

with episodes with high impact

on life are good candidates for the

MC intervention.

Projects are in line for completion

in 2020: Francesca Wuytak

(Development of a core outcome set

for Pelvic Girdle Pain; A systematic

review, qualitative interviews

and Delphi consensus study); Jan

Hartvigsen (CARL, the International

Chiropractic Research Leadership and

Capacity Building Program); Richard

Nicol (Development of an ICFbased

assessment schedule for manual

medicine) and Lise Vilstrup Holm

(The effect of chiropractic treatment

on infantile colic: A randomised

controlled single-blind study) are all

busy completing their projects in

2020.

Six projects are scheduled to

be completed in 2021: Cecilie

Krage Øverås (Pain in the spine

and elsewhere - patterns and

consequences); Sidney Rubinstein

(Spinal manipulative therapy for

acute low-back pain: systematic

they did not experience as much

pain in the pain relapse. These

patients also reported longer time

between relapses, compared with

the control group. This amounted

to nearly ten pain-free weeks for

the one-year duration of the trial.

It is clear that MC is

highly effective for a certain

psychological group of patients

with recurrent and persistent LBP;

the dysfunctional group. It is also

clear that the effect of fewer ‘days

with bothersome pain’ is achieved

by ‘flattening’ the pain curve

as well as extending the time

between relapses.

• The full text can be accessed

at https://tinyurl.com/y4oxz3j4

review and meta-analysis); Petra

Schweinhardt (Phenotyping

low back pain – a prospective

observational pilot study); Damian

Bailey (Relationship between physical

activity, low back pain and cognitive

impairment. A cross-sectional and

longitudinal analysis of data from the

Danish Twins Registry) and Andreas

Eklund (Development of a clinical

stratification instrument to improve

cost-effectiveness of Chiropractic

Maintenance Care).

Mauritz van Tulder (Back

Complaints in Elders (BACE): A

prospective, longitudinal analysis of

older people with low-back pain in

chiropractic care) has been granted

an extension due to Covid-19 and

is now expected to complete his

project in 2022.

Sarah Thurøe (Growing pains

in Danish children: A quantitative

and qualitative description) and Jan

Hartvigsen (CARL II) are expected

to be completed in 2023 as planned.




Research

Research Corner:

Null-Hypothesis Statistical Testing and

the problem of inductive reasoning

Sidney Rubinstein, DC, PhD, Jonáh Stunt, PhD

IN THE previous research

corner, we discussed Null-

Hypothesis Statistical Testing

(NHST) and the p-value. In

this article we want to elaborate

on a fundamental problem with

this approach: the problem of

inductive reasoning.

Key points

• Null-Hypothesis Statistical

Testing (NHST) is based upon

inductive reasoning.

• This approach can introduce

error because conclusions are

based upon the probability of a

given observation, particularly

when the likelihood is low.

• NHST and p≤0.05 were

never meant to be a basis for

conclusions, but only meant as a

means to disprove a hypothesis.

In order to understand the situation

better, it is important to understand

what NHST-reasoning entails.

NHST is framed as a deductive

argument and follows a rule of

inference. An example, put simply:

• If it rains, the road is wet;

• The road is dry;

• Thus: it is not raining.

However, this approach

does not always lead to correct

conclusions, even if both

conditions (i.e. the first two

statements) are true. Suppose

you buy a lottery ticket and win.

We all know that the chances of

winning the jackpot are extremely

small. If one were to formulate

a hypothesis about the chances

of winning the jackpot, it would

take the following form, using the

modus tollens framework:

• If the lottery is fair (H 0 ) then

the chance of winning the

jackpot is very small (x);

• I won the jackpot (x);

• Thus: the lottery is unfair

(reject H 0 ). [whereby H 0 is the

null-hypothesis and ‘x’ is a given

probability]

Everyone would agree that it

would be incorrect to conclude

that the lottery is false based upon

the fact that you won it. Yet, we

follow this exact same line of

reasoning when we use NHST.

So, where does the NHST line

of reasoning go wrong? It has

to do with probabilities. To

understand this, let’s go back to

the experiment with the coin

which we used as an example in

the previous edition. If you want

“This

introduces the

importance of

understanding

that a theory

can never be

proven, only

disproven.”

to determine if a coin is fair (or

true), you toss the coin a number

of times, count the number of

heads and tails, and calculate the

probability of that observation

given your null hypothesis. The

probability of throwing heads or

tails is equal, so if you were to toss

the coin five times and the coin

lands on ‘heads’ every time, this

probability would be (0.5) 5 =0.031.

Quite a small chance, and you

would question the fairness of

the coin. Suppose we were to

toss the coin a thousand times

and every time the coin lands on

‘heads’. The probability of that

happening with a fair coin would

be (0.5) 1000 which is a probability

of practically null. This would be

very strong evidence for an unfair

coin. However, the probability

is not zero! Meaning, a fair

coin could result in a 1000 times

heads if we were to toss a coin an

infinite number of times, albeit

the probability is extremely low.

Following the NHST-reasoning,

we would conclude that the coin is

not fair and thus reject H 0 .

Even though the suspicion of

a false coin is high, observations

cannot provide definitive

proof. This is exactly the

problem surrounding inductive

reasoning and explains why

the modus tollens framework of

reasoning may lead to incorrect

conclusions with NHST. The

Scottish philosopher David

Hume identified this problem

in the 18th century. Simply put,

definitive proof cannot be attained

in empirical and inductive ‘open

systems’, which is in contrast to

deductive closed systems, such as

mathematics. In such systems as

the empirical sciences, definitive

proof is impossible because one

cannot sample ALL subjects

or ALL situations which fulfil

the study criteria. Consider, for

example, subjects with neck or low

back pain. It is simply impossible

to sample everyone on this planet.

Suppose you formulate the

hypothesis that all swans are

white. One would expect that

every swan you observe would

be white, and every observation

to be confirmation of this

hypothesis. However, one black

Sidney Rubinstein

Jonáh Stunt

swan would be enough to dispel

the hypothesis. This introduces the

importance of understanding that

a theory can never be proven, only

disproven.

In short, conclusions based

upon a limited number of

observations may be false.

However, just as it is impossible

to sample ALL swans, it is equally

impossible to sample ALL subjects

with neck and/or low back pain.

NHST relies upon probabilities;

however, as with the lottery

or coin tossing example, these

probabilities are not zero, and

therefore, potentially valid.

The founding father of NHST

(Fisher) never suggested that

NHST and p≤0.05 are a basis

for conclusions. He considered

a small p-value as an outcome

interesting enough to warrant

further research, NOT proof.

“The null hypothesis”, he said,

“is never proved or established,

but is possibly disproved, in the

course of experimentation. Every

experiment may be said to exist

only in order to give the facts

a chance of disproving the null

hypothesis.”



Education

Updates from the EAC

Tom Michielsen, Chair of the EAC, reports

New process for awarding

CPD hours

CONTINUING PROFESSIONAL

Development (CPD) is any learning

outside of undergraduate degree or postgraduate

degree formal education. It aids the development

of knowledge and the maintenance of skills in all

areas of chiropractic professional practice.

The EAC is committed to facilitating and

promoting CPD among its members. In the

latest survey done by the EAC and completed

in March 2020, approximately 25% of

respondents use the ECU website and app to

find available CPD events. In 2020 we have

been working with CPD providers to increase

the number of evidence-informed CPD

seminars in the ECU calendar. In the current

world environment, we strive to support ECU

members by filling the calendar with quality

online CPD options. Equally, once face-to-face

CPD resumes, we will continue to strive to fill

the ECU calendar with quality seminars.

For the EAC to maintain high levels of

lifelong learning, it will award CPD credits

to seminars, conferences and other learning

which it considers are of a standard to merit

formal recognition.

The criteria for the awarding of CPD hours

and details of the new accreditation process

can be found on the ECU website under the

Education and CPD tab.

We have been developing a new process

to assess events according to the criteria for

the awarding of CPD hours. Now including

a panel process with subject area specialists

in the event topic, it has been piloted with

success over the past year and will be used

going forward.

If you do run CPD events in Europe

and would like to submit your CPD event

for EAC accreditation, please look at

the ECU website for further details or

contact eacjacquir@chiropractic-ecu.org.

There is no charge for applying for

accreditation and we are happy to help you

through the process.

GEN-C

The Global Education Network for

Chiropractic (GEN-C) released many new

modules to support chiropractors with their

CPD during the Covid-19 lockdown. Nine

video courses (15 CPD hours) and 15 journal

articles (15 CPD hours) are freely available to

ECU members, 600 of whom are already using

the service. For your free access, please contact

your national association.

We are committed to producing more

quality evidence-based modules; a video

course on how to engage with the elderly was

published by Stan Innis recently, and modules

by Alice Kongsted and Peter Tuchin are due for

publication soon. Chiropractors who complete

a module successfully will receive a certificate

that can be downloaded and submitted to a

CPD administrator.

ChiroRecruit – a Swiss recruitment campaign

TWENTY-TWO STUDENTS

started their chiropractic studies at

the University of Zurich in September

- more than last year – but the national

association, ChiroSuisse, wants many

more students. To increase the number

of chiropractic students, ChiroSuisse is

running a recruitment campaign that

targets high school students.

Students who are about to graduate

from high school have to decide what

they want to study. To help them with their

choice of studies, universities and high schools

organise study information days, which is

where the ChiroRecruit campaign begins.

ChiroRecruit is a professionally designed

social media campaign that targets young people

aged between 16 and 23. The aim is to make

high school graduates aware of the great career

opportunities of chiropractic. To reach them,

ChiroSuisse developed information material

in all three official languages, and placed social

ads, mobile display ads and audio ads on

channels like Snapchat, Instagram, YouTube and

Facebook. Normally, they also present at the

information days with their own branded booth.

Virtual study information days

The University of Zurich kicks off the season

of study information days, but this year, due to

Crack your future – study chiropractic!

With this slogan, ChiroSuisse has been running

a social media campaign since last year.

This pocket guide (folded to the size of

a credit card), as well as other campaign

material, can be ordered by interested high

school students.

The campaign material in French, German

and Italian can be ordered

the pandemic, the days were held virtually,

and the association had a virtual booth on

a platform for virtual visiting days. All the

material, including videos, pictures, links etc,

was uploaded and a podcast was produced in

which two young chiropractors explain the

chiropractic course. And there were four live

chats of 45 minutes where questions from

future students were answered.

Since no personal meetings were possible,

and it was important to get the e-mail

addresses of interested young people, they were

encouraged to take part in a quiz or to order

information material for free.

via the website www.study-chiropractic.ch

With the allocated financial contribution

from ECU over the next five years,

ChiroSuisse will be able to continuously

develop the campaign and ensure a

sustainable growth of the profession.




Feature

Knowledge translation in chiropractic:

Is research supporting practice?

From time to time we offer a guest spot for chiropractors to discuss relevant

topics. This is a guest perspective by Daniel Moore, Chiropractic Course

Leader, Teesside University

REMEMBER SEEING the sign: ‘Please don’t walk on the

I grass!’ It was 2004, and I was embarking upon my first degree

when I experienced a first spark of interest in knowledge transfer.

Do people walk on the grass? Now, 16 years later with a very wellestablished

interest in knowledge, its dissemination and how we

monitor that, I find myself pondering the same kind of questions.

With regard the chiropractic profession, is research impactful? Do

guidelines have high levels of adherence?

The very recent update to the 2018 Lancet series on lower back

pain highlights, in part, the lack of guidance adherence, leading to

low-value care still being all too common in the management of lower

back pain. So, are we looking in the right places for the answers?

In this article, I hope to address what knowledge translation

is within chiropractic, what human traits affect it, and the

importance of monitoring it. My aim is to spark your interest, so

we all can endeavour to think more around this important topic.

Transfer and translation

I believe this is a necessary distinction to make. To transfer

something is to take it and disseminate it to another group.

Translation is to take something, repackage it to be understandable

or usable to a certain group or a given context.

Transfer, in making people aware that research exists, does happen

in health care and certainly within chiropractic. For example, in the

UK, via the Royal College of Chiropractors (RCC), I received seven

‘New Research Article’ emails containing up-to-date research links in

July 2020. In my view, this is a good example of an effective transfer

of knowledge. However, are these emails read and understood and

do they have an effect on the people who read them?

This is where the concept of translation starts to become

important. In health care we also have clinical practice guidelines.

For example, in the UK the National Institute of Clinical

Excellence guidelines NG59 & CG177 are both very relevant to

chiropractors. The RCC over recent years has also produced eight

quality standards, the most recent of which addresses headaches,

and outlines in a concise and understandable document what a

care pathway for this presenting complaint may look like. This, in

my view, is a good start to knowledge translation.

Who reads these important guidelines?

I am confident that many conscientious chiropractors do read

these quality standards and guidelines. However, we don’t really

know how many! They are surely introduced at an undergraduate

level and, as I am developing the chiropractic course at Teesside, I

will undoubtedly embed these useful tools within the course. This

will likely have a positive impact but is not sufficient in itself.

In 2004 John Gabbay and Andreé le May coined the term

mindlines, as opposed to guidelines. They identified that in general

medical practice, people didn’t read guidelines. Clinicians valued two

things; what they had been taught (existing knowledge), and what

their peers knew. So, coffee room chat was often the way in which

problems were solved, or queries were answered, rather than clinicians

referring to the most recent edition of the British Medical Journal or

similar publication. Peer knowledge often beats research evidence.

In addition, psychology comes into play. Nobel Prize winner

Daniel Kahneman articulates very well in his book Thinking, Fast

and Slow just how much we resort to cognitive ease over cognitive

strain as a natural reaction to inquisition. Read this short puzzle

Kahneman created and listen to your intuition:

A bat and ball costs £1.10p

The bat costs £1 more than the ball.

How much does the ball cost?

Your intuition likely says ten pence? But you feel uneasy about

that answer. You now can’t work it out because one part of your

brain won’t let the ten pence answer go. The ball costs 5p, the bat

£1.05p (one pound more). This demonstrates our mind’s desire

to be a little lazy, and if something in context makes sense, we’ll

probably accept it.

We also naturally sell ourselves the value of our decision over an

alternative option requiring more cognitive effort. In The Chimp

Paradox by Steve Peters, it is shown that the chimp often wins,

and we use intuition and emotion to make decisions instead of

rational thinking. We must understand the impact psychology has

in research translation, and not be naive to human behaviour.

Where do we look next?

I believe the general consensus would be that research supports

many aspects of practice, and that the value of informed

chiropractors, with a current, up-to-date knowledge base, is an

accepted standard. Guidelines provide a great tool to translate

often long and complex research articles into usable information

for chiropractors. However, often by their nature they struggle

to account for clinical context, varied contextual factors and

individual circumstances. So, investigation to understand these

varied knowledge sources in more depth, within a particular

context, while taking account of the psychology of decisionmaking

could be extremely valuable to our profession.

This discussion, as well as how we demonstrate our translational

competence over time as we move further away from our

undergraduate education, and how our psychology and social

environment impact our decisions in practice, could be the

necessary focus of our future investigations.

It is likely that people don’t walk on the grass… but it’s not

because of the sign.



General news

Students are now

also members of

ChiroSuisse

ALMOST ALL chiropractors

practising in Switzerland are

active members of the professional

association ChiroSuisse. Up

to now, however, chiropractic

students have been denied

membership. A year ago,

ChiroSuisse’s General Meeting

adapted the statutes in order to

admit students. At the same time,

the voting rights for assistants in

the mandatory two-year postgraduate

education were also

adopted.

Chiropractic students at the

Medical Faculty of the University

of Zurich were contacted and

invited to submit membership

applications. The Association

of Swiss Chiropractic Students

(SCS) decided at the AGM to

submit a collective application

and to automatically link the

membership at SCS with a

membership at ChiroSuisse. All

Swiss people currently studying

chiropractic abroad were also

personally contacted. All have

accepted this invitation and

applied for membership.

Admission of all

chiropractic students

At the ChiroSuisse General

Meeting on 7 May this year,

which took place virtually due

to the pandemic, 95% of the

members voted in favour of the

motion to admit all chiropractic

students. The association has thus

grown by 124 members at once.

Thomas Thurnherr, President

ChiroSuisse, commented: “It

was one of my election promises

that as President of ChiroSuisse,

I would support the younger

generation. I am very pleased that

we have now been able to send

a strong signal in this direction

by admitting the students to

our professional association.

They should now be given the

opportunity to help shape their

future role as key players in the

health care system.”

Involvement of the

new members

Although students do not have

the right to vote or to be elected,

ChiroSuisse wants to involve

the younger generation in the

decision-making process on

forward-looking professional

policy issues and thus give them

the opportunity to actively shape

their future. With the involvement

of students and the new voting

and election rights for assistants,

ChiroSuisse is sending a clear

signal of its willingness to align

the association's strategy with the

ideas of the next generation.

Noel Schürmann and Daniel

Koller, Co-Presidents of SCS, said:

“We students greatly appreciate

the various contacts with

chiropractors and the new student

membership at ChiroSuisse

shows us that we are accepted

and welcome. This gives us the

opportunity to become more

involved in shaping our future

together with the experienced

chiropractors, from which both

sides should benefit. We are

looking forward to the coming,

common tasks.”

In Switzerland, almost 100% of

practising AND future practising

chiropractors are now united

in one association. This gives

ChiroSuisse an extraordinarily

strong voice.

Charlotte Schlaepfer,

Communication Manager,

ChiroSuisse

Lebanon achieves

recognition for

chiropractic

Stathis Papadopolous reports

IN MAY this year the President

of the Lebanese Chiropractic

Association, Dr Haifa Abouassi,

announced the passage of

legislation regulating the

chiropractic profession by the

Lebanese parliament. This

historic achievement follows

years of active lobbying by

the Lebanese Chiropractic

Association. The new law

provides for chiropractic

licensure in Lebanon with

statutory recognition.

The new chiropractic law

in Lebanon is a hard-won

achievement following years

of lobbying, meetings, and

phone calls with members of the

Lebanese Medical Syndicate,

lawyers, judges, ministers,

and members of parliament.

Since 2015, the Lebanese

Chiropractic Association has

engaged in countless hours

of meetings, with numerous

drafts being written and

rewritten, objections from the

Medical and Physiotherapist

Syndicates being submitted,

and strident objections from

Lebanese University officials.

The Lebanese uprising and the

coronavirus pandemic added

further challenges. The passing

of chiropractic legislation comes

after chiropractors rejected the

terms of a law drafted by the

Lebanese Ministry of Health and

Welfare, which insisted on referral

from a medical practitioner as

well as prohibiting use of the title

Doctor

It has been officially

announced that, having

met worldwide chiropractic

standards, native Lebanese

chiropractors will be able to

practise in Lebanon.

Licensure under the Act

is restricted to Lebanese

citizens who have undertaken

a prescribed programme

of education and passed

a colloquium examination

conducted by the Ministry of

Education in Lebanon.

The Act makes specific

reference to the evaluation,

analysis and examination of

biomechanical defects of

the joints (which it defines

as subluxations) in order to

establish and perform the

necessary treatment for

correction. It further refers to

the prescription of exercise and

therapeutic advice related to

the spine. Drug prescription

and the performance of surgery

is expressly forbidden in the

Act and compliance with public

health regulations regarding

clinic facilities is described.

Provisions for disciplinary

sanction are also included.

Practising chiropractic without

a licence is outlawed under the

Act. Dr Abouassi commented:

“Despite all these hurdles, a

small group of chiropractors

and their ardent supporters and

enthusiasts never gave up. They

continued lobbying and fighting

until the law was finally passed

without any specific stipulations

or limitations. I am extremely

proud and overjoyed to be

surrounded by hard working

and dedicated colleagues who

laboured tirelessly to bring the

skill, care, effectiveness, and

benefit of this unique profession

to the people of Lebanon.”




General news

More action needed to implement

The Lancet papers’ recommendations

FOLLOWING THE seminal

papers of 2018, The Lancet

recently published a call for

action to improve treatment and

eliminate waste associated with

care for low back pain.

The main messages are that low

back pain is still the number-one

cause of disability in the world,

many patients with low back pain

are still receiving the wrong care,

much of the money spent on

low back pain care is wasted and

better policy solutions are needed;

to maintain the momentum of

improvement, ten actions are

recommended:

1 Health care funders should

stop paying for ineffective and

harmful tests and treatments,

and commission research on

those that are unproven.

2 New tests and treatments

should not be marketed,

introduced into practice, or

publicly reimbursed, before

they have been adequately

tested for safety, efficacy, costeffectiveness.

3 Health and social services

should work with employers to

provide support that stimulates

early return to work, and work

conditions that are adapted to

employee capacity.

4 Patients should be taught to selfmanage

low back pain and seek

care only when really needed.

5 Widespread and inaccurate

beliefs about low back pain

in the population and among

health professionals should be

challenged, and the focus put

on reducing the impact of low

back pain on people's lives

rather than seeking medical

treatment for a cure.

6 Clinical pathways, care plans,

and other standardised tools

managing low back pain should

be redesigned to integrate

health and occupational care,

but only after establishing their

comparative effectiveness and

cost-effectiveness.

7 Payment systems and legislation

should be changed to encourage

delivery of the right care.

8 The World Health Organisation

should support new public

policies and urgent political

action to ensure strategies are put

in place to reduce global disability

from low back pain as a priority.

9 Research and funding bodies

should invest in an intensified

research effort to address gaps in

the understanding of low back

pain, as well as implementation

research to determine how best

to put existing knowledge and

evidence to use.

10 Journals and the media should

have greater editorial and

peer-review oversight to ensure

that trial results are accurately

portrayed and do not reflect

unwarranted belief in the

efficacy of new or established

but unproven therapies.

Covid-19

Covid-19 and sports chiropractic

Ulrik Sandstrøm reflects on the past few months

WE HAVE all struggled with

our professional identity

during whichever lockdown our

government chose to impose on

us. It is amazing what happens to

your psyche, when your ability to

practise your vocation gets taken

away from you, and you realise how

much you define yourself by what

you do. As sports chiropractors, we

have felt this too. Most of our clubs

shut their doors, seasons were being

cancelled or postponed and players

were sent home with ‘work-ons’

from the medical team to keep

them in some sort of shape during

lockdown. Apart from the buzz of

dealing with your athletes and your

friends in the medical teams, we

also had to deal with no sports on

TV. Except for re-runs of the 2012

Olympic games (in the UK!) and

more Tours de France than I care to

remember. There was no challenge

of ‘who can we get fit for Saturday’

or keeping an eye on your team’s or

athlete’s results over the weekend.

And, of course, the postponement

of the Tokyo 2020 Olympic Games

was the final blow.

Some of us kept in touch with

athletes over video link as clubs

were returning to training in small

clusters and some clubs were testing

all staff twice per week. Some

sports chiropractors are back in full

swing, whilst some are still waiting

on the sidelines. My rugby club

has returned a minimum number

of medical staff and with as little

hands-on as physically possible

which means that I am not yet

involved as I write this piece.

My personal tele-health

triumph has a little sports flavour

to it, although the mode of injury

was lifting a sofa rather than being

tackled by a large prop. Patient

presented on my Zoom screen

with his arm stuck in 30 degree

abduction explaining that this

happened three weeks ago, the

doctor had diagnosed a ‘rotary

cuff’ (!) and it was going to be

six weeks before he could have it

scanned. After a brief exam via



General news

video, I told him that the only

shoulder injury I could think of

which restricts adduction to this

degree was a dislocation. You can

imagine his disbelief that this may

have been missed by the doctor

and he was less than keen on

presenting to the local emergency

department. I persuaded him, sent

him off with an email from me to

ensure the staff took it seriously

and 30 minutes later he was under

general anaesthetic to have his

shoulder relocated.

The other exercise related

injuries I dealt with over Zoom

were generally in people deciding

to embark on a fitness regime

over lockdown, as some of

them overcooked their activities

dramatically. Joe Wicks, the UK

based online fitness guru, was

generally the cause of many a

patient realising that being fit

for walking and cycling doesn’t

mean you can launch yourself into

squat thrusts and burpees without

paying the price. This was met with

questions about whether these were

‘bad exercises’ - followed by my

second favourite mantra: ‘There is

no bad exercise – only exercise you

are not prepared for’.

Now that we are back in clinic,

a lot of the athletes are streaming

in, realising that their regular

maintenance chiropractic checkups

really did keep them going; and

that three to four months without

care have taken their toll. Some of

our regular competitive runners

and cyclists have found that cross

training and new sports have kept

them fit and less bored. Others

disappeared into three months of

eating, drinking and the general

disappearance of life routines,

which meant that their regular

exercise went out the window too.

They are now presenting to all our

clinics as they jump straight into

deadlifting their old weights in the

newly opened gyms, confirming

my very favourite mantra: ‘Most

people injure by doing too much

too soon – after doing too little for

too long’.

Never let a good crisis go to waste

We asked leading chiropractors how they think the chiropractic

profession should respond to Covid-19

Tony Accardi CAI The demands of the pandemic have taught us many lessons, among them

the importance of time efficiency, efficiency in daily activities, patient

examinations, communication and delivery of care.

Guillermo Busto AEQ Covid-19, the subsequent lockdown and the associated increase of

musculoskeletal disorders, should be a clear reminder of the importance of

having good health, and produce important changes in people's lifestyle,

including an increase in the percentage of the population that choose to

receive chiropractic care.

Philippe Fleuriau AFC

Vasileios

Gkolfinopoulos

The chiropractor must refocus on the needs of his patients through honest

care, as close to scientific data as possible.

ECU President Adaptation and speedier evolution are key elements to a successful

response to any crisis; hence, the chiropractic profession must mature and

get realistic about the delivery of health care during and after Covid-19.

Jan Hartvigsen NIKKB Chiropractors should show that they can be helpful in other ways than

manual treatment, such as by promoting self-management through advice

and teleconsultations.

Lone Kousgaard

Jørgensen

Greg Kawchuk

DKF

University of

Alberta

Always evaluate new procedures introduced in an emergency as they might

be better than the things you used to do; and look further ahead to see

how you can enhance resilience in the long run.

Now that Covid-19 has shown how tele-health can extend practice, let's

keep going to help patients for whom distance and/or disability prevent

them from seeking care.

Alice Kongsted NIKKB Chiropractors have the opportunity to show that information, advice and

coaching are central, and often sufficient, elements of chiropractic care.

Olivier Lanlo IFEC This crisis is a unique opportunity to rethink our teaching methods and to

implement new skills and competencies when it comes to chiropractic care.

Tom Michielsen EAC We are overwhelmed with scientific evidence on mask efficacy, Covid-19

transmission rates, lockdown effect and many others; knowing how to read,

judge and apply this evidence is crucial to surviving the crisis and gaining

skills in critically reading evidence will greatly increase our credibility in

health care systems.

Espen Ohren NKF Associations must get more involved with government and health

authorities; the more they know about chiropractors’ knowledge, diagnostic

skills and success in enabling people to be economically productive, the

more they will value us and listen to what we have to say.

Stathis

Papadopoulos

Cyprus

Chiropractors’

Association

The profession should emphasise our drug-free clinical results, safety, and

cost effectiveness.

Steffen Stumpp DCG Chiropractic is about movement, life is about movement, and now it's about

the movement of our perceptions.

Thomas

Thurnherr

ChiroSuisse

While the whole world is busy fighting a communicable disease,

chiropractors have a great opportunity to demonstrate the importance

of their role in the management of one of the most prevalent noncommunicable

diseases.

Gitte Tønner NCA In the face of unprecedented crisis outside wartime, by the NCA staying

rational, reasonable and firm on the points that we are fully qualified health

care providers, that we deliver safe, effective and cost-effective care, we

have proven ourselves to be mature partners and worthy of the Health

Ministry’s time in upcoming conversations about securing the position of

chiropractic in The Netherlands.

Bart Vandendries BCU

Jan Geert

Wagenaar

ECU Vice

President

In times where social distancing is the new normal, the privilege of being a

chiropractor with face-to face close contact and a hands-on approach with

patients has become even greater; the positive contextual effects of these

'touching' encounters can hardly be overestimated.

Being touched and touching someone else are fundamental modes of

human interaction; the chiropractic approach, being safe, patient specific

and hands-on will become even more important for patients’ wellbeing.

John Williams AIC Research illustrates how NSAIDS and other pharmaceutical treatments for

musculoskeletal pain have undesirable consequences involving the immune

system; we should emphasise the successful treatment of musculoskeletal

pain by chiropractic, drug-free care.

Kenneth Young UCLAN Build on the increased awareness of the usefulness of multidisciplinary

clinical and research health care teams, and on the visible strong public

support for the heroes in the national health systems.




Covid-19

The associations during the

first wave of Covid-19

In April the ECU waived the Spring dues for all member associations to help them weather

the Covid storm. In September ECU members showed solidarity with the British Chiropractic

Association agreeing to its request for the BCA’s ECU Autumn dues to also be waived.

Ian Beesley, Secretary General, explores here how associations fared between March and

August, and is grateful for information provided by the presidents of ECU member associations in

Belgium, Denmark, Germany, Ireland, Italy, The Netherlands, Norway, Spain and Switzerland.

DURING MARCH, most

ECU member associations

advised their members to close

clinics, shortly after the World

Health Organisation (WHO)

had declared a global pandemic.

Thereafter, clinics responded to

health authority guidance that

acute patients could be treated,

provided that treatment was

essential and social distancing and

hygiene guidelines were strictly

observed. The green light to open

for non-urgent care came after

varying periods over the months

of May and June. Typically, clinics

remained substantially closed for

two months with chiropractors

eligible in some countries, but by

no means all, for government aid.

Uncertain of the likely duration

of hardship, the ECU Executive

Council first decided to defer the

Spring dues to the Autumn but

subsequently proposed to the

General Council that the Spring

dues should be waived altogether.

This proposition was accepted by

vote and announced on 20 April.

Confusion and

ambiguity

The challenge facing associations

was (and to some extent remains)

complex – even in countries

that had previously identified

a global pandemic as a major

threat to their populations, and

in some cases had conducted

contingency planning exercises

to test emergency procedures,

events moved fast. Inter-country

competition for medical supplies

intensified as it became clear that

the understanding of the disease

was poor, and responsibilities were

divided. ChiroSuisse had to deal at

first with 26 Cantons; in Germany

the initial responsibility lay with

the 16 Länder before being taken

over by the federal authorities. In

Spain the chiropractic association

(AEQ) had to deal with 17

regions. Scotland, Wales and

Northern Ireland asserted their

independence from the United

Kingdom; they could not (and still

cannot) agree on common policies

or on co-ordinated phasing of

measures to combat the pandemic.

In some cases risk aversion became

the unwritten association rule.

The health authorities in every

country were faced with a rapidly

moving situation affecting every

aspect of economic and social life.

A key question for governments

was what could sensibly be

designated essential and at what

cost in risk to the population?

Several rulings seem strange in

hindsight: Italians could not

move more than 80 metres from

their homes, Spaniards could

not exercise outside the house.

Italy suspended autopsies. As

a small health care profession,

chiropractic could not expect to be

covered explicitly in government

pronouncements, even where

it is regulated. Yet individual

chiropractors understandably were

looking to their associations to be

told what they should do and what

would constitute a valid assessment

of acute need. Existing contacts

between associations and public

health authorities demonstrated

their worth. The federal authorities

in Switzerland helped ChiroSuisse

source face masks at the time of

greatest shortage. In Denmark,

after a couple of weeks, the

“The more that the authorities

know about us... the less likely

they are to close us down...”

National Health Care Authority

(Sundhedsstyrelsen) took the

view that it was important for

the health care system to remain

open and all critical functions

maintained. These included

treating conditions such as acute

pain and ongoing programmes

where postponement would lead

to a worsening outcome with

an enhanced risk of disability.

Some clinics never closed. By

14 April Sundhedsstyrelsen had

published a plan for returning

to normal practice, allowing

most treatments whether acute

or for maintenance. Currently,

chiropractors In Denmark need

not wear facemasks, gloves or other

protective equipment, though they

must observe guidelines regarding

social distancing in waiting rooms

and hygiene measures before and

after seeing patients.

In Belgium, as there were no

specific guidelines for chiropractic,

a long-standing contact in the

cabinet of Minister De Block

validated association guidance

to postpone maintenance and

non-urgent care until early

April. The Belgian association

(BCU) emphasised that whilst

each clinician had to decide for

themselves what constituted

need for care, they should not

feel obliged to provide it if their

personal circumstances would be

greatly compromised. As from

4 May, government advice on

an exit strategy from lockdown

pointed to a gradual enlargement

of access to health care consistent

with avoiding saturating the

medical services dealing with

the virus. “This does not mean

business as usual,” stressed the

association, “as clinicians will still

have to continue with the safety

and hygiene measures put in place

in the earlier part of the year.”

In Norway the association

(NKF) persistently posed questions

to the ministries and health

authorities, on a daily basis, until it

was given identified ‘point-persons’

to handle queries. An appearance

of the NKF president on national

television helped stimulate an

official response that, as responsible

health care professionals, clinicians

could determine which patients

were in acute need of care. In

Ireland, a radio interview with

a lady who had been severely

injured when a driver committed

suicide by driving into her head-



Covid-19

on and was now dependent on

chiropractic care considerably

raised the profile of the profession.

In other countries, such as Italy

and Great Britain, an uncertain

legal situation and the social

distancing or hygiene requirements

led the associations to recommend

closure. In Germany, new

government regulations were

twice published on a Friday

afternoon and it was unclear if

clinics could remain open on the

coming Monday. Only after help

from the association’s lawyer and

last-minute telephone calls to the

relevant federal offices of health

did confirmation come that clinics

could remain open for acute

patients.

In several countries there

are reports of closer regular

contact with similar health care

professions. ChiroSuisse met

MDs on a weekly basis, the NKF

started close collaboration with

the optician and physiotherapist

associations and are still enjoying

good relations and weekly

contacts. The Netherlands

(NCA) collaborated on letters

to the ministry and the media;

the associations in Britain joined

physiotherapists, osteopaths and

others representing 300,000

largely self-employed people in

open letters to ministers calling

for financial support for those left

outside the government economic

support. The NCA has established

a good relationship with the

National Health Inspectorate.

Strong contact with

members

Every association faced an

urgent need to ramp up their

communications with members,

who were looking for reassurance

and information that they could

trust. In promoting decisive

government action, the print and

television media contributed to

a climate of fear made worse by

inadequate real-time statistical

information. Some association

members were angry that clinics

were being advised to close and a

lively debate opened up in many

countries between members who

supported closure as a sensible

precaution and those who

thought that chiropractors should

demonstrate their belonging

to the frontline health care

teams by remaining open and

relieving pressure on the hospital

emergency departments and the

family doctors. The Chiropractic

Association of Ireland (CAI)

reported, for instance, that the

vast majority of its members

saw chiropractic as essential and

argued: so why not offer care

during an emergency provided

that we exercise extreme caution?

Frequent messages that

provided reassurance because of

their realism, honesty and tonal

quality shored up the morale of

clinicians, in contrast with media

reports inciting fear and doom.

The association in Italy (AIC)

produced 11 webinars, two hours

of television and short videos with

practical advice for those working

from home. The NKF met daily

and issued a 15-30 minute video

of the day to all members with

an up-to-date daily newsletter

containing the latest information

and a section answering members’

questions.. All of this put great

pressure on association board

members who were often recruited

into taskforces – the CAI, for

example, established four: dealing

with the government financial

provisions for support, safety

precautions, public relations and

monitoring of relevant research.

Spain took an innovative approach

by setting up a covid taskforce

with membership of two AEQ




Covid-19

executive members, three other

AEQ members, a medical doctor,

a researcher, and a representative

of chiropractic patients. A

ChiroSuisse taskforce met daily.

Surveys of members in Belgium

and Norway produced approval

ratings of 90% for how the

associations helped their members.

Safety

Initially at least, the shortage of

personal protective equipment

(PPE) was a significant barrier to

offering even acute care. Belgium

and France dipped into reserves

to source an initial supply of PPE

for members – and the BCU

continues to purchase surgical and

FFP2 masks to be made available

to its members at cost price.

Other associations, including

Spain and Germany, circulated

lists of suppliers whilst respecting

government requests not to

jeopardise supplies to those in the

covid front line.

Screening of patients before

accepting appointments,

maintaining adequate social

distancing between patients,

controlling the numbers in waiting

rooms and frequent use of hand

gel or hand washing have become

quite normal. In Great Britain

advice to leave a 15-minute gap

between patients in a treatment

room is severely reducing the

capacity of those clinics that

follow the advice. In other

countries the requirements are less

extreme, and a German laboratory

has recently reported favourably

on a one-time spray coating of

surfaces that offers a 12-month

protection against the virus.

The President of the German

association describes a typical

setup: “Signs are up on front

doors, receptionists screen during

phone calls for relevant symptoms,

the demand for overpriced

disinfectant has skyrocketed.

Door handles are disinfected on

a regular basis, chiropractors’

hands are disinfected more than

skin can handle. Waiting times

are minimised, chairs in waiting

rooms are removed, chiropractors

wear facemasks, some even face

shields… the list goes on.”

Nevertheless, by August many

associations were reporting strong

demand for chiropractic care.

Belgium and Switzerland were

estimated to be back to 80%

activity, Italy was back to 75%

within a week, Denmark reports

higher-than-ever bookings. In

the Netherlands, NCA members,

along with those in some other

countries, report that they are

working longer hours and there

have been few if any bankruptcies.

In Britain the demand appears

to have rebounded strongly

and clinics have resumed

advertising for associates, but

the recommended hygiene

requirements have seriously

reduced capacity.

Looking to the future

– innovation and

resilience

Whereas the take-up of

teleconferencing has been

largely universal across Europe

(including an Annual General

Meeting attended by 240 people

in Spain), the take-up of teleconsultation

has been mixed and

there are different views on how

far this innovation will persist.

The Scandinavian chiropractors

have found patient resistance

to be high, making it harder to

justify the investment required in

clinics. By contrast, in Ireland two

of the three main insurers have

agreed to reimburse patients for

tele-consultations, and in Belgium

chiropractors are using Physitrack

to create exercise programmes for

patients and to observe how they

carry out the exercises. In England

at least one progressive clinician

has used Slack to maintain contact

with patients. Across the board,

there are reports of widespread

satisfactory tele-consultations

involving family doctors which

are delivering significant

improvements in efficiency and

time management.

The rapid and agile adjustment

required to digest and act on

changing requirements from

the health authorities – in some

cases involving 350 – 400 pages

of government instructions each

week – needs to be replicated

in response to changing market

circumstances. Where chiropractic

is unregulated, there are reports

of increased competition from

other professions. Looked at

from a patient perspective,

aspects of diagnosis and advice

on exercise, nutrition and lifestyle

are seemingly well-suited to teleconsultation.

Also, contact with

existing patients during lockdown

has highlighted the importance

to patients of reassurance. How

to monetise this technological

innovation remains to be solved.

Advances in communication

with public health authorities

must not be allowed to slip back.

As Espen Ohren (president of

the NKF) says: “The more that

the authorities know about us,

understand the contribution

chiropractic makes to lifting the

burden on doctors and hospitals,

and hear about the success of

chiropractic care in enabling

people with low-back pain to

continue to be actively employed,

the less likely they are to close us

down when, inevitably, there are

future pandemics or subsequent

waves of the covid threat.”

Steffen Stumpp of the German

Chiropractors’ Association advises:

“Talk about health solutions not

surveillance and apps; be calm

and do not add to the inevitable

confusion.” Nor should we ignore

that chiropractors are individuals

too, with fears, anxieties and

susceptibilities to stress. It is

now recognised that sad things

happen in hospitals and that

hospital doctors can suffer from

post-traumatic stress requiring

counselling. In the words of the

Gospel according to St Luke:

“Physician, heal thyself.”

ECU Humanitarian Award

In 2016 the ECU announced a

new award – for outstanding

humanitarian work by a chiropractor

in the field. To date three such

awards have been made:

• Bélen Sunyer for chiropractic

care for the homeless and

refugees in Madrid.

• Dinos Ramon for care in the

refugee camps for people

displaced by the Turkish invasion

of Cyprus in 1974

• Sven Boehne of the AIC for his

on-site pro-bono care of the first

responders following the Italian

earthquakes in central Italy in

2016.

There have been many heroes during the Covid-19 pandemic. If you

know of a chiropractor who has used their professional knowledge,

skills and competence to do something extraordinary for the

community, please let us know at info@chriropractic-ecu.org by

sending a citation describing their efforts and the contribution made.



Covid-19

Reflections on pandemics

through history

Ian Beesley, Secretary General, considers what we can learn from previous pandemics. This article draws

extensively on the archive of History Today and Prospect Magazine; other sources include a staff report

in MPH online, and The History of Plague by John Frith in the Journal of Military and Veterans’ Health.

IN 1789, after reaching agreement

on the US Constitution,

Benjamin Franklin offered the view

that “in this world nothing can

be said to be certain except death

and taxes”. He might have added

pandemics to the list. A cursory

internet search points to three

great outbreaks and many lesser

ones of bubonic plague, numerous

widespread outbreaks of influenza,

not to mention AIDS and cholera.

Traces of influenza have been

found in bones dated to 1200 BC

in central and southern Asia but the

first recorded warning of calamitous

disease imported through the trade

routes of the day occurred in 430 BC

in Athens. Though it was not until

the influenza outbreak of 1889 –

1892 that the term pandemic came

into general use to define a sudden

and geographically widespread rapid

explosion of a disease. Modern

interconnectedness and the associated

concept of ‘going viral’ to cover a

wide-ranging rapid expansion of

ideas, images and influence perhaps

points to a future wider definition.

The Athens epidemic of 430

BC was graphically described by

Thucydides. It spread inland from

the port. Symptoms included

sickness, retching, hoarseness,

coughing. Bodies became hot and

tender and painful pustules broke

out on the skin; patients had a

raging thirst. Health care workers

were particularly at risk. Social

order broke down. Citizens stopped

respecting the gods and the disease

affected how Athens could prosecute

its war with Sparta. It also killed the

greatest Athenian statesman of the

day, Pericles. The type of epidemic is

unknown, but speculation points to

typhus or smallpox.

Fast forward to the Antonine

plague of AD 166 in the reign of

Marcus Aurelius, which affected

Asia Minor, Egypt, Greece and Italy,

being brought to Rome by soldiers

returning from Mesopotamia. In

a society where life expectancy

was already as low as the mid-20s,

the outbreak (possibly smallpox

or measles) severely depleted the

Roman army.

Almost 400 years later in the

Justinian Plague of AD 541 victims

had the characteristic symptoms of

bubonic plague. Believed to have

originated in Ethiopia it was carried

on ships along Mediterranean

sea trading routes, reaching

Constantinople in the autumn

of 542. A conservative estimate

of deaths in Constantinople is

5,000 a day – in total 100 million

fatalities by 546 across Asia, Africa

and Europe. Food production was

severely disrupted and an eight-year

famine started. The outbreak was a

significant contributor to the demise

of the Justinian reign and the end

of Roman rule, ultimately leading

to the fragmentation of Europe and

subsequent nationalism.

Next in the pantheon of

pandemics is an event that every

schoolboy and schoolgirl recognises.

The Black Death that ravaged

Europe between 1347 and 1352

once again originated in Asia Minor

where the Tatar armies of Khan

Janibeg, unsuccessfully laying siege

to the town of Kaffa, succumbed

to bubonic and then pneumonic

plague. In an act of vengeance,

they tossed infected bodies over

the walls of the city causing the

Genoese traders there to flee in

panic. Thus, the plague was spread

by the globalised transport of

the day, ships, moving across the

Mediterranean to Southern Europe

and up to the North, arriving in

Oslo in 1348 and being conveyed

by ships of the Hanseatic League to

Sweden, Denmark and Germany.

A ship could travel 40 kms a day,

560 kms every fortnight - around

20 times faster than land transport.

The plague was initially spread by

rats’ fleas, but then transmitted

human to human when it became

pneumonic; recent estimates put

the number of deaths at between

50 and 80 million people, 60% of

History Today

the European population. This led

to dramatic shortages of labour and

an emerging middle-class of vílleins

who were able to extract huge

increases in pay and land from the

dominant aristocratic landowners.

By 1430, the population of Europe

was lower than it had been in 1290

and would not recover to pre—

pandemic levels until the sixteenth

century.

There were an estimated 30

waves of the plague over the next

300 years. It is during this period

that the use of quarantine to

safeguard the healthy population

was first introduced (in Venice

in 1374) later including isolation

for selected travellers from the

eastern Mediterranean for 40 days

(quarantena), from which the term

quarantine derives. Also during this

time plague doctors in the Low

Countries introduced a primitive

form of personal protective

equipment of a covering of leather

or oilcloth, leggings, gloves, hood, a

wide-brimmed hat which denoted

their medical profession, and a

beak like mask with glass eyes and

two breathing nostrils filled with

aromatic herbs and flowers to ward

off infection. They avoided contact

with patients by taking the pulse

with a stick, issued prescriptions

passed through the door, and lanced

buboes with knives several feet long.

In late 15th and early 16th

century London outbreaks, theatres

were closed with the result that

Shakespeare had to diversify away

from writing plays to writing

fashionable contemporary poems

known as epyllion – high-end softporn

poems aimed at young men in

the London Inns of Court urging

them to carpe diem amid multiplying




Covid-19

deaths. The most famous of these is

Venus and Adonis, published in 1593.

Shakespeare possibly also wrote the

tragedy King Lear during plagueinduced

quarantine in 1606. Nor

was he alone in putting what we now

call lockdown to good use - Isaac

Newton discovered gravity whilst

in his garden during isolation and

experimented with the use of prisms,

leading to the conclusion that the

colours of the rainbow lie behind

light. Daniel Defoe wrote Journal of

a Plague Year, lamenting that “private

mischief won the battle against

general benefit” with people fleeing

to the countryside and spreading

infection. Isaak Walton penned Th e

Compleat Angler in 1653 as homage

to life in the countryside.

My final example has to be

the three waves of the misnamed

Spanish Flu pandemic of 1918-20.

(Not until 2015 did the WHO

recommend that diseases should not

be named geographically.) There

was a death toll of over 50 million

(often those who were young and

fit), far higher than the numbers

killed in the First World War. There

was widespread volunteering to

help fellow citizens, often with

accompanying self-sacrifice. Doctors

had been conscripted into the

frontline armies for the Great War

and, as a result, many of the sick

were left to fend for themselves. It

is a sobering thought that only 100

years ago we were still 12 years away

from the invention of the electron

microscope and 15 years away from

the isolation of the influenza virus.

Knowledge of the past can only

do so much. In 2020, on the day

that China reported a tenfold

increase in coronavirus cases,

Adam Kucharski, a professor at the

London School of Hygiene and

Tropical Medicine, published Th e

Rules of Contagion which wryly notes

that epidemiologists are prone to say,

“If you’ve seen one pandemic you’ve

seen… one pandemic”. All play

out differently and understanding

contagion has contributed

significantly to the reduction

of death rates from infectious

diseases in the past 20 years. One

finding is that understanding the

nature of what society faces in any

pandemic is crucial. It took two

to three years to discover the HIV

pathogen; how remarkable it is to

think that the Covid-19 pathogen

has been discovered, sequenced

and incorporated into a test kit so

quickly.

One area where the past probably

is a good guide to the immediate

future is in the human and political

reaction to pandemic. We have

seen the best and the worst of

international behaviour – from

collaborative research efforts for a

vaccine to ‘beggar-my-neighbour’

policies interrupting the supply

chain for protective equipment.

In many countries we have stood

at our front doors or on balconies

during lockdown to applaud the

heroes of our frontline health

systems. This first response of

solidarity in the face of sudden

unexpected events is profoundly

human, but it is hard to judge

the significance of events whilst a

participant. History suggests that

this recognition of heroes will be

followed by a hunt for villains. In

the inevitable public enquiries that

will follow, those in authority will

seek to apportion blame. “Which

country handled the situation best?”

will be a central question,

followed by “Why wasn’t

it us?”

What becomes habitual

during a pandemic (particularly

if there are successive waves)

will become the new normal.

Thus, the current pandemic

has dramatically stimulated the

demand for teleconferencing,

an existing under-utilised

technology, and online shopping.

As I write, Marks & Spencer,

iconic symbol of the British

High Street, reports a reduction

of 60% of in-store trade partially

offset by an increase (from a much

lower base) of 40% in online

shopping. It is not alone in this

experience.

The longevity of recently

introduced tele-consultation and

telehealth is still unclear, but

chiropractors will be well advised

to consider how their economic

resilience can be made stronger,

especially if there are subsequent

waves of infection, as seems highly

likely.

Political leaders of the profession

must look to the identity and

position chiropractic occupies in

the health care system and the

members of their associations

will also expect leadership in the

challenge of personal survival in

a further lockdown or stringent

public health requirements. The

chiropractic schools in Europe have

shown great agility in responding

to the challenges of lockdown and

social distancing (see page xx); they

have changed for ever and will be

the better for it.

Politicians seek to weaponise the

crisis for political ends. They liken

the fight to control pandemics

to war in calls for solidarity and

sacrifice. And the analogy of war

is not entirely misplaced. War and

pestilence are a great stimulus to

innovation, both because new

things are discovered and because,

under the stress of a mortal

threat, unrealised

demand for

existing

underutilised

discoveries comes to

the fore. Recent

research, for

example, has revealed

how the introduction

of canvas baths

on the frontline

during World

War I to combat

disease spread by

lack of hygiene,

and to combat the boredom of

much of life in the trenches, led

to increased demand for home

bathing in domestic life from

returning soldiers, with consequent

improvements in public health.

Of course, the main challenge is

medical - to stop the spread and to

prevent deaths. But the after-effects

will be geopolitical, economic and

social. In 1910–11, for example,

following an outbreak of plague in

Manchuria, Britain, Japan, Russia,

Germany and France scrambled to

offer help with the not-so-hidden

intention of improving their

chances of colonial expansion. So

now, China has turned the tables

to present itself as mentor to much

of the rest of the world and was in

the forefront of public ceremonies

creating honorific martyrs from its

frontline workers

A Cambridge historian of

science has reminded us that

epidemics breed fear and suspicion,

multiplying more rapidly than

any virus. As a result, fault lines in

society are revealed and exaggerated.

If the past is a guide, the people

will question the motives of elites

who are seen to have benefited from

the crisis. There will be renewed

interest in the structures and ethics

that constitute good government.

Exceptionalism has been ruthlessly

exposed as flawed and dangerous.

The tendency to accept a victory

of emotion over fact, spurred on

by social media, may be shortlived

as frightened people yearn

for information from sources they

can trust. A tightened relationship

between national politics and

personal values, first observed by

social historians in the aftermath

of 17th century crises, may be

repeated.

It is worth reflecting on the

certainty that at the end of the

current pandemic, what we will see

will not mark the end of the struggle

between virulent infectious disease

and humanity.



Covid-19

Covid-19: How did the chiropractic

schools of Europe cope?

The WHO declared a pandemic on 11 March 2020. By 18 March normal teaching had ceased

across European chiropractic schools, which then took on the challenge of continuing the

education of students under lockdown. The following is a summary of how this was achieved.

Eleven ECCE accredited schools were invited to contribute to this article and thanks go to AECC

UC, Barcelona, IFEC, LSBU, McTimoney, RCU (Madrid CC), SDU, Teesside, UCLAN, and WIOC.

Online learning and practical

sessions

WHILE CHIROPRACTIC courses

based on university campuses were

dependent on wider university instructions for

their lockdown learning plans, the independent

institutions were able to make their own decisions.

• Typically, the first week of lockdown

was spent retraining faculty in distance

learning, which went live in week two for

theory sessions using a variety of platforms

(Blackboard, Loom, Moodle, Teams, Zoom)

and a rescheduled curriculum. In some cases,

students coached faculty in the use of these

platforms - an example of reverse learning.

• Practical modules were restructured with

a mixture of mannequins, anatomage and

permanent groups of students (bubbles)

under supervision by one member of faculty.

Bubbles ranged in size from 6-8 to 20-40

depending on the availability of safe space.

Complex allocation patterns made sure that

students living in the same accommodation

were allocated to the same bubble(s) which

remained constant for all training in

technique etc. Faculty often had to work

extra hours as a result.

• IFEC reopened on 1 June with around

50% of students electing to go onto campus

periodically.

• At least in the immediate future, costs

will rise because of requirements to source

personal protective equipment (PPE). Some

of the larger institutions are severely affected

by this, particularly where students’ physical

presence on campus resumes close to the

traditional levels, partly in response to the

potential loneliness of distance learning.

Learning outcomes and exams

All schools reported that learning outcomes had

been maintained.

• At SDU 80-85% of courses could be

delivered online – a figure that seems to be

typical amongst all schools. This was partly

because the lockdown came close to the end

of teaching.

• Exams on theory were switched online

backed up by tried and tested invigilation

processes (e.g. the Norwegian INSPERA)

and programs used in the universities

to detect plagiarism (e.g. TURNITIN)

(WIOC).

• At the RCU students were allowed to

consult texts etc., as is allowed in some exams

at McGill in Montréal, for example, where

time pressure to complete complex tasks does

not easily lend itself to extensive searching.

Students were told this was a test of their

ethics as well as knowledge.

• Videos of students from earlier years carrying

out adjustments were used in McTimoney, as

practices to be critiqued by current students.

• Videos of students from earlier years carrying

out a range of patient encounters were used

in McTimoney, as learning opportunities for

current students in clinic.

Collaboration

There was little guidance from health care

authorities specific to higher or further education.

• Where chiropractic courses run alongside

other health care courses, a feeling of

solidarity in the face of new and threatening

circumstances often arose and collaboration

across disciplines was much improved.

• At Teesside and London South Bank

University, the physiotherapists are trialling

virtual placements and several schools

reported improved opportunities for future

collaborative modules.

• Attendance at faculty meetings also improved.

Patient clinics

Two clinics stayed open for acute cases, staffed

by faculty (Madrid and McTimoney).

• These and all others which have now opened,

have revised procedures to incorporate

remote triage before an appointment, and

strict hygiene measures for staff and interns

involving sanitising gel, frequent wiping

down of surfaces and wearing PPE consistent

with practice in the rest of the country.

Masks, scrubs, shoes, in some cases visors,

are in use. The use of gloves is less prevalent

– a typical response is that of IFEC where

frequent use of sanitising gel is preferred.

• Face-to-face appointments are being staggered

to reduce congestion in the corridors, with




Covid-19

the consequence that capacity is reduced to

between 40% (IFEC), 66% (AECC) and

70% (WIOC) but supplemented by telehealth

appointments for those at risk.

• Barcelona reported a slow start when the

clinic re-opened, followed by a rapid upsurge

when it became apparent that the clinic was

safer to visit than the local hospital A&E/

emergency departments.

• No reduction in patient waiting lists was

reported.

• Upper back and neck pain complaints after

working from home during lockdown appear

to be increasing

The effects on students

With campuses closed most students went

home – often facing 14 days’ quarantine – and

followed the online courses.

• Contact with students became a pressing issue

with faculty concerned that loneliness and

anxiety would affect them. Significant extra

effort went into pastoral care, including a

manned telephone hotline open 24/7 at BCC

and at Teesside University, food delivery was

arranged for those of its 18,000 students in

university-recognised accommodation.

• Seminar discussions critiquing the use

of technique helped maintain a sense of

belonging.

• The SDU reports that a significant challenge

in the immediate future will be to improve

student well-being and maintain their

motivation to avoid drop-out rates rising if

there is a second wave of the pandemic.

• The improved intensity of communication

with students brought immediate benefits. In

some cases feedback suggested that previous

perceived remoteness of faculty was reduced,

and relationships moved closer to that of

mentor and pupil.

Managing graduation

Most institutions involved the student body in

deciding how to handle graduation.

• In some cases, graduation was simply

postponed until it is safer (IFEC, WIOC and

AECC). In others, ceremonies were virtual,

leaving celebration events to be organised at a

later date (SDU, RCU, LSBU).

• Only in Barcelona was the traditional

graduation ceremony held, though on a

severely restricted basis which allowed only

45 of the 250 places to be occupied and with

the event live streamed for guests.

Positive change for the future

The use of online resources and attention to

students’ wellbeing have produced positive

results.

• The switch to online teaching of theory is

expected to continue in the future (SDU,

WIOC) at least to some extent (BCC).

• An unexpected benefit is that institutions

may be more inclined to invite teachers with

specific knowledge from around the world to

give online lectures (SDU).

• The role of faculty may move closer to being

mentors and coaches.

• Weaker lecturers will become more exposed.

An important lesson is that production

values for online sessions will only need to be

good enough; television and film production

values have been shown to be unnecessary

• Students will have greater freedom to study

for a significant part of the time from

anywhere in the world. Universities with

marketing operations in the Far East and

the Asian sub-continent may be attractive to

chiropractic students.

However, increased demands on time for the

supervision of practical classes may squeeze the

available time for research.

Possible developments in

course content

Course content will need to be responsive to

changing public health advice, particularly on

disease prevention and clinical hygiene.

• There will be some scope for re-purposing

physical space due to the switch to online

teaching.

• The pandemic has made faculty question

why things are done in a certain way and has

raised the awareness of flexibility (AECC);

innovation will be accelerated (Teesside).

It will bring into further focus the debate

between courses built around traditional

contact hours and those more weighted

towards competencies, opening up new

possibilities in conversion courses and parttime

courses.

• National governments are likely to press for

lower cost and speedier university courses

more generally.

• Nutrition, a healthy lifestyle, disease

prevention and a contribution to the quality

of life are likely to feature in future courses

(UCLAN). However, all the institutions

interviewed agreed that there is no scientific

evidence that chiropractic adjustment boosts

the immune system.

• There may be more emphasis on life events,

the human life cycle and the care of different

generations.

Early indications are that the demand

for chiropractic education may rise as a

consequence of the higher profile for health

care workers during the pandemic, and possibly

the perception of the profession as taking the

strain off other hard-pressed parts of the health

care system.

But SDU and WIOC add words of caution:

some of the spike in interest may be a shortterm

phenomenon connected with the decrease

in travel, fewer young people going on gap year

voyages and higher unemployment as a result

of Covid-19.

The ECCE has postponed planned re-accreditation visits

to WIOC and Barcelona



Review

Musculoskeletal Pain –

Assessment, Prediction

and Treatment:

A pragmatic approach

David M Walton, James M Elliot

Handspring Publishing; ISBN13:978-1-912085-50-7

Reviewed by David Byfield

REALLY LIKE this book for many reasons.

I It is well organised into relevant chapters,

is nicely illustrated and well referenced for

the reader to explore the subject further. The

authors make it clear that musculoskeletal

(MSK) pain affects millions of individuals

worldwide and represents a significant

contribution to both pain and disability

affecting overall quality of life and therefore

requires a thoughtful and methodical approach

to manage these conditions.

The book also presents a clinically pragmatic

approach to the management of MSK pain,

incorporates an evidence-based biopsychosocial

methodology and has been produced by two

very experienced physical therapist research

academics.

The text describes a comprehensive and yet

manageable plan for assessing a person’s pain

and disability experience, using a seven-point

radar plot to establish a profile representative of

the various components of the biopsychosocial

model. The authors state that the radar plot is

not a panacea, but provides a framework and

some structure for clinicians attempting to

make some sense out of a highly complex field

of human experience.

At the heart of the book is the assess,

predict and treat framework which advocates a

common-sense approach to managing patients’

complaints by conducting a sound, inclusive,

critically informed and clinically relevant

assessment of the patient (including a welldocumented

history, subjective narrative and

objective clinical tests). The next component

of the framework allows the practitioner to

‘predict’ the likelihood that the patient will

improve on their own or respond to a particular

treatment intervention and then introduce

a treatment plan based upon the assessment

and prediction. The authors state that

although this is an obvious approach to

clinical practice, it is their experience that

many clinicians find this clinical reasoning

process and application very difficult and

tend to manage patients from a biomedical

perspective, implementing similar treatment

protocols for different patient presentations.

This is not a radical departure from current

routine clinical practice, but more of a repackaging

to foster skill development and an

appreciation for the value and limitations of

relying solely on research, clinician experience

or patient values in isolation.

In order to properly implement the assess,

predict and treat framework, clinicians must

possess considerable knowledge on the choice,

application and interpretation of clinical

assessment tools (effective interview skills,

interpretation of self-reporting tools and

clinical tests). Clinicians also must be able to

combine and use those findings to mentally

construct a multidimensional profile of the

patient, identify important patterns in their

presentation, possess an understanding of the

evidence base pertaining to MSK conditions

and effective interventions designed specifically

for each patient. This book applies coherent

and logical principles to encourage patientcentred

decisions for a very complex clinical

picture. The framework encourages treatment

decisions that flow naturally from assessment

and prediction as the method identifies the

primary drivers of the patients’ pain and

disability and leads the clinician to decide if

treatment is indicated from a prognostic point

of view and what treatment is indicated.

The bulk of the book includes a series

of chapters to support and explain the

background knowledge and underpinning

science of the proposed framework to provide

the reader with more detail and rationale.

I am particularly pleased to see a detailed

breakdown of the various components that

make up the biopsychosocial model and how

these mechanisms contribute to a patients’ pain

and disability experience and how clinicians

can incorporate this knowledge in their clinical

assessment, prediction and treatment plans.

I highly recommend this new book to all

clinicians managing MSK conditions and

to the educational community, as it takes a

comprehensive and multifactorial approach

to manage the complexity associated with

the clinical presentation of MSK pain.

There is enough pain science to make this a

contemporary contribution to the expanding

literature, assisting clinicians and educators

to update their knowledge base and helping

to bring together important clinical evidence

in the treatment of a wide range of MSK

conditions. I feel the authors have successfully

met their objectives in documenting their

evidence-informed methods.

Professor David Byfield is Head of Clinical Services at

the School of Health, Sport and Professional Practice in

the Faculty of Life Sciences and Education, University

of South Wales

Handspring Publishing has offered BACKspace

readers a 10% discount on the price of this book. Buy

through https://tinyurl.com/y32mmfw8 and use code

WaltonBS10 at checkout.




People

Making a commitment

In the mid-1990s, when the Anglo-European College of Chiropractic (AECC) was one of very

few places in Europe where you could study to join the profession, three young men moved to

Bournemouth, UK to join the AECC’s first five-year Masters in Chiropractic cohort.

VASILEIOS

GKOLFINOPOULOS

was a former Greek water polo

champion who had studied sports

science. Rishi Loatey was a London

teenager who, by chance, met and

observed a chiropractor at work

and changed all his education

plans. And Jan Geert Wagenaar had

been a professional footballer and

a qualified physiotherapist in the

Netherlands before he decided that

chiropractic was more effective!

From three very different lives, they

were drawn together by a common

desire to become chiropractic

health care professionals.

Their names are, of course,

very familiar. These three, who all

graduated from AECC in 1999, are

now the ECU’s President, Treasurer

and Vice-president respectively.

How was it that they came together

as a formidable Executive team

after two decades building their

separate lives and careers?

The power of making a

career change

Being flexible enough to change

your mind, or your direction,

when better information presents

itself, is one of the attributes the

Executive team members share.

When Vas arrived at AECC, he

had never received a chiropractic

adjustment! But when he was a

child, his father would regularly

travel 200km to Athens to see a

chiropractor: “I clearly remember

how my dad used to rave about how

fine he was after each treatment”. A

few years later, as a member of the

Greek national youth water polo

team, Vas sustained a bad shoulder

injury: “I received really bad care

from the team physician and ended

up with surgery - my shoulder never

recovered, and it ended my career. I

was a student of sports science, but

that experience made me want to

change to musculoskeletal health

care. I went to the UK, toured a

range of osteopathy, physiotherapy

and medical schools, but chose

AECC, where I felt very much

at home because of childhood

experience.”

Rishi too, as a teenager, decided

to change his career path when he

discovered chiropractic: “Coming

from a typical Asian background,

I didn’t want to do medicine

so thought I’d study economics

and work in the city. By chance,

through my family’s business, I

met chiropractor Robert Bridges,

and ended up observing him and

also another chiropractor, Brian

Hammond, at work. As a result, I

changed my A levels from maths,

economics, geography and French

to maths, biology and chemistry

and went down to AECC! There

were very few of us then who

came straight from school – and it

changed my life.”

Jan Geert didn’t so much change

his career as add chiropractic to

it: “During my active years as a

professional footballer I also went

through my physiotherapy studies.

I incurred a back injury, and

managed to keep playing while I

was injured, though not helped

by several visits to the team’s

sports doctor, physiotherapist and

manual therapist. But two visits

with my mothers’ chiropractor got

me fit and fully recovered and on

my way to chiropractic college.”

Learning to lead

All three have felt the need to be

part of the guiding forces behind

the profession. Having become

successful chiropractors, running

businesses and raising families

in their home countries, all have

also represented chiropractors in

various executive roles at national

and European level.

Vas was president of the Greek

Chiropractic Association for 14

years and served eight as treasurer

to the ECU before becoming its

president. However, he insists,

you have to understand what it

is to be a follower first: “In order

to become a leader, you to need

to understand the other side

and know how it feels to be led.

That’s when you start figuring out

what kind of leader you would

prefer to be, so if you become

that leader, you know. I enjoyed

and learned a lot in my eight

years working next to Øystein

Ogre during his ECU presidency.

Leading is not easy, and most of

the time it’s lonely and stressful,

but it’s my way of giving back,

of improving things rather than

complaining about them.”

Rishi served on the BCA

Council for some years before

becoming ECU treasurer in

2018 while also running his own

multidisciplinary clinic and a

complementary medicine training

centre in West London. His aim

has always been to help people be

the best they can be – and that

includes not just patients but

chiropractic graduates and other

therapists too: “It’s important to

me to pass on the knowledge and

experience I have gained after 20

years in practice.”

A love for working as part of a

team, since his footballing days,

is crucial for Jan Geert’s view of

leadership: “ I served as Student

Union president during my time

at AECC, and spent six years

as president of the Netherlands

Chiropractic Association before

becoming ECU vice-president.

My love for working in a team

was cultivated in my years as

© Øistein Holm Haagensen

Vasileios Gkolfinopoulos

Rishi Loatey

Jan Geert Wagenaar



People

a professional footballer, when

being part of a team meant that

every day you pushed each other

towards more and better, while

building friendships and having

so much fun together. Above all,

there was a sense of team spirit

to achieve that common goal,

which is why I believe in the need

for solidarity and the necessity of

unifying the profession.”

Ambition and vision for

the profession

Since 1994, when they began

their chiropractic journey, there

have been many changes in the

way chiropractic is viewed and

accepted, but it is still far from

reaching its full potential as an

effective musculoskeletal health

care profession addressing the

leading global cause of disability.

For Vas, the way forward is to

take some very brave decisions:

“We need to become more relevant

by endeavouring to provide what

society needs. We are in a position

to help with major issues, and we

need to be brave enough that if we

discover that if we need to reinvent

ourselves, we must do it.”

The ultimate aim for Rishi is

that all European chiropractors

get the cultural authority of a

dentist or an optician, becoming

the first call for back and spine

problems: “Countries’ health care

systems would then buy into that,

including our use of imaging.

To achieve that, we need more

educational establishments, and

more research – and of course the

ECU has a big part to play.”

Jan Geert agrees with both of

them: “Law and policymakers are

not interested in just a good story

and the wonders of our profession.

We need to make them realise

that back pain remains the leading

global cause of disability overall,

putting great pressure on society

and reducing economic potential.

It’s up to us, the chiropractic

politicians, to present the research

and show them how chiropractic

can play a positive role.”

The class of ‘99

What was it about that class of ’99

that brought this Executive team

back together after 20 years to work

for chiropractic advancement?

First – commitment. Self-funding

a five-year education, whether that

involved help from parents, weekend

and holiday working or both, was

(and remains) a huge commitment,

and requires total dedication to

success, and to chiropractic. Rishi

points out that for British students

like him, at that time, medical

school was free, so stepping ‘out

of the system’ and studying a

profession few knew about required

courage! The dedication all three

demonstrated then has clearly

continued through their careers.

Second – making change in

‘the real world’. Vas and Jan

Geert have learned through their

sporting careers the way that

chiropractors can affect people’s

everyday performance, and the

way that sports can ‘shine a light’

on chiropractic. Rishi is still

amazed today at what a difference

chiropractic can make to so many

different conditions, and how

powerful and life-changing the

profession can be.

And third – trust. Vas has the

final word on that: “AECC in the

1990s was very multicultural, very

colourful, a fun place to be (the

parties were epic!) and it was a

one-degree school where everybody

knew everyone and it was a very

enjoyable experience. So, when

Rishi, Jan Geert and I came back

together from our different cultures

and backgrounds, it helped that we

knew each other way back then,

before we had confidence in what

we could become. This creates a

different kind of trust – we grew

and matured together, and became

chiropractors together, and we

don’t forget how we all were on

day one, which perhaps helps us to

work together now.

“The ‘99 class, looking back,

includes a lot of successful people

around the world. It was a good

batch!”

60-second

interview

BACKspace interviews figures from the world

of chiropractic

Jesper Hjertstrand

WIOC/ECU Graduate of the Year 2020

What is your career history?

Previously I worked as a swimming coach

in my native Sweden as well as in Australia

and Lebanon. I was in Lebanon on and

off for five years during which I got

increasingly more and more responsibility

to the point where I eventually helped run

a large sports academy together with its founder.

What attracted you to chiropractic?

While I was studying Exercise and Movement Science in Australia,

a professor pulled me aside and told me that I seemed to have a

real knack for anatomy and physiology. He advised me to look into

suitable studies to become a medical doctor, a physiotherapist or

a chiropractor as he thought this would suit me well. Chiropractic

attracted me the most, both professionally and personally.

What is your most memorable professional moment?

I haven’t been in clinical practice that long but one story that

stands out to me thus far is a young man who came into the

university clinic with multiple previous fractures of his lower back

and one lower leg. At the start of my enquiry and examination

he wasn’t very talkative but later on he opened up and shared

with me that his injuries were the result of a failed suicide

attempt. As health care professionals I feel we have such a

privilege to be able to share patients’ stories and be part of

their life, and with that hopefully bring them something good.

On the other hand, we also have a huge responsibility which we

should not take lightly and that requires appropriate levels of

professionalism. In this case, I was able to help the patient get

back to a more active lifestyle with less pain while co-managing

with other appropriate health care providers. This encounter was

such a valuable lesson to me as a young clinician and is one that

I will cherish for the rest of my life.

What are your ambitions?

At the moment, Iben Axén, Andreas Eklund, Per Palmgren

and I are finishing up a manuscript that should be published

shortly as part of the Nordic Maintenance care programme.

This opportunity, to be part of research at Karolinska Institutet

in Stockholm, has been a true honour. Inspired by this, I

will soon be starting my second Master’s degree, this time

in Exercise Physiology and Sports Medicine. With deeper

knowledge within this field I aim to conduct research in a not

too distant future, hopefully combining my love for sports with

my profession as a chiropractor.

During day-to-day clinical work I strive to provide the best

possible evidence-based care for every patient’s individual

needs under the construct of the biopsychosocial model of

health care. I have the great fortune to work in a multidisciplinary

environment where I’m sure I will continue to learn from my

colleagues and thereby advance further as a clinician.

Contact

jesper.hjertstrand@gmail.com




People

Charley Bennett

AECC UC/ECU Research Award winner 2020


I’m currently in my final year at the Anglo-European College

of Chiropractic University College. I am now an intern at the

on-site clinic in Bournemouth. I originally started a degree

in Clinical Exercise Science but swapped to the Master of

Chiropractic programme. I have had a few part-time jobs but it

only strengthened my drive to become a chiropractor.


From a young age, I knew that I wanted a career that involved helping others and I

always had a keen interest in anatomy and physiology. I knew that health care was the

path for me, but I was never exactly sure what branch I would pursue. I contemplated

physiotherapy, dietetics, medicine but it was chiropractic that grabbed my attention. It

was when I had some hip issues myself that I discovered the world of chiropractic. I saw

an intern at the AECC UC and after speaking with her, I knew that it was something I

had to know more about. I took a gamble and applied to the AECC. I was lucky enough

to receive an offer to start studying chiropractic and since then I haven’t looked back! I

love the profession and how much we can help our patients with a holistic approach.


I have to say, the day that I treated my first patient was one of the most memorable

moments for me. It felt as though my years of studying was paying off and for the first

time ever, I was able to help someone and put my skills to good use. It was such a

rewarding feeling when the patient left and said that they already felt relief.

I would also say the reward that I have received for my research project. I based the

project on a condition that is close to my heart as it is something that I suffer with myself.

I hope that my project can contribute to the field and that I can help with future research.


I am excited to graduate next year and I hope to one day open a clinic of my own with

my younger sister. I also hope to continue working on other research projects that will

help to educate myself and other health care professionals and better the care we

provide for our patients.

Contact

17113@aecc.ac.uk

Marcin Dochnal

The first officially recognised chiropractor in the

Czech Republic and president of the new Czech

Chiropractic Association.


I was born in Poland and emigrated with my family to Canada

at the age of seven. For a long time, I knew I wanted to return

to Poland or Central Eastern Europe closer to my wider family

and culture. Upon finishing my Science degree in Canada, I

moved to the UK to study Chiropractic at the AECC. I was then fortunate to work in

two great chiropractic clinics in the UK and learn valuable skills from Stefaan Vossen

and Jasper Hulscher.


In my early teens I wanted to be a dentist. However, after an injury and help from a

chiropractor when I was 16, I quickly learnt that chiropractic is cleaner, more enjoyable

work and I still get to help people.


My most memorable professional moments were my encounter with my very

first patient at the AECC clinic, who was a contortionist, treating the band at a

MEGADETH concert, and realising I knew very little on my first day at work!


My ambitions are to facilitate the growth of chiropractic in Central Eastern Europe.

I strive to provide a healthy and safe environment for my family. I also hope not to

catch covid and not to get shut down by the authorities!

Contact

marcin.dochnal@gmail.com

Daniel Moore

Chiropractic Course

Leader, Teesside

University

What is your career

history?

I graduated in 2007 with a

BSc (Hons) Earth Sciences

from the University

of Leeds before moving to London to work

in business and recruitment. This was a great

experience, but I increasingly felt it was not a

career for me. I wanted to spend my working

life committed to helping others outside of the

world of business and sales. In 2009 I started my

chiropractic degree at WIOC and graduated in

2013. I completed my PgCert in MSK Diagnostic

Ultrasound the same year. From there I moved

into a private practice which had been established

by my wife (also a chiropractor) in 2006


My main motivation was a desire to spend

my working life in support of others. I was

interested in a career in manual care, and

neuromusculoskeletal conditions. I was also an

athlete and understood the tenets of optimising

human performance, and chiropractic helped me

perform at a level I previously struggled to attain.

What is your most memorable professional

moment?

I have worked in football which led me into pitch

side emergency care, and my interest in education

led me to become an FA Medical Tutor. I have

worked with the British Masters Athletics Medical

Team at multiple events nationally, but most

importantly cared for my community over the

last seven years through our clinic. But, without a

doubt, being handed the opportunity to design

and then lead a new chiropractic degree course

in the UK has to be the highlight of my career

to date. It encapsulates my interest in leading

outstanding, clinically led chiropractic education. I

can add value to the continuing endeavours aimed

at strengthening our profession. Arguably most

important of all, I can help to create excellence

in an expanding profession for the benefit of all

future patients seeking outstanding chiropractors

in many different settings.


My primary ambition is to support the

development of outstanding EPIC chiropractors

who graduate as excellent health care

professionals, professional in how they act and the

decisions they make, and highly skilled in how they

adjust, speak to patients and behave. Teesside

University has the potential to contribute greatly to

the world of chiropractic education and I am keen

to drive that contribution through research and

collaboration. I also strive to support the vision of

chiropractors being EPIC; evidence based, people

centred, interprofessional and collaborative. With

more outstanding chiropractors, a world leading

institution and a world leading EPIC vision, it is

hard not to see a bright and exciting future ahead.

Contact

D.Moore@tees.ac.uk



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