THE BIG CHIROPRACTIC NETWORK IDEA. PIPEDREAM OR INEVITABLE?

Introduction

The chiropractic profession has started to recognize the inherent value and role of practitioner and academic networks. Collaborative research networks are increasingly used as an effective mechanism for accelerating knowledge transfer into policy and practice. Academic research networks, whether they be formal national networks, social media platforms, or research programs, serve to facilitate collaboration, knowledge dissemination, and problem-solving within the academic and research community.¹ New research networks are regularly emerging, strengthening and developing research economies and shifting the global balance of research activity. Increased connectivity and collaboration have advantages, such as knowledge transfer and an increase in cited, co-authored works.²

There are chiropractic practiced based research networks which include existing, developing and now defunct networks. These are international (the ICPA-PBRN),³ Nordic,⁴ Canadian,^5,6 USA,⁷ Swiss,⁸ UK^9,10 and Australian.^11,12

There are relatively few academic and research networks. There is the Letters of the Chiropractic Academy (LOTCA) (only open to those with a PhD),¹³ the Patrons of Chiropractic Science (PCS),¹⁴ and the relatively recently formed Chiropractic Educators Research Forum (CERF).¹⁵ The Manual Alternative and Natural Therapy Index System (MANTIS)¹⁶ and Chiro.org - Chiropractic Resource Organization¹⁷ are other groups that serve to inform the evidence base of the profession.

Educators and institution groupings include the Association of Chiropractic Colleges (ACC)¹⁸ and the Rubicon group.¹⁹ Accreditors are based within the Councils on Chiropractic Education International (CCEI)²⁰ and the Council on Chiropractic Education (CCE).²¹ The Council on Chiropractic Education Australasia (CCEA), is the body responsible for accreditation of chiropractic programs in the Australasian region.²²

Regulators in Australasia are the Chiropractors Registration Board of Australia (CBA)^23,24 and Te Poari Kaikorohiti o Aotearoa, (The New Zealand Chiropractors Registration Board).²⁵

In Australasia there are 3 membership organizations, the Australian Chiropractors Association (ACA),²⁶ Chiropractic Australia (CA),²⁷ and The New Zealand Chiropractors Association (NZCA).²⁸ ACA represents roughly 50% (3,000) of Australia’s chiropractors, CA ~25% and around 25-30% are not members of either organization. CA, the organization formerly known as the Chiropractic and Osteopathic College of Australia (COCA), lists over 1,500 members; however, its membership is also open to osteopaths.

There are several categories of chiropractic stakeholder networks, organizations, and regulators where innovative networking and collaboration may address a ‘silo’ isolationist dynamic. This concept/hypothesis paper discusses how existing networks and stakeholders can be harnessed to address challenges facing the chiropractic profession concerning data gathering about research priorities and beyond. The concept derived from a study canvassing research priorities of Australian chiropractors is presented.

The project had originally aimed to identify and compare the research priorities and perspectives of practicing chiropractors and academics in Australia. Of interest were their views on existing and future research strategies and funding initiatives as well as their research and publication activity. However, during the project, challenges of gathering robust data especially on the research and scholarly activities of the profession prompted novel ideas of how to address obstacles around data clarity, validity, reliability, and accountability.

Methods

Using the STROBE cross-sectional checklist to inform the project²⁹ in 2018-19, my team devised and circulated a questionnaire to identify and rank research priorities amongst key chiropractic stakeholders in Australia, and also to examine research capacity and output of the Australian chiropractic profession over the preceding 5 years.³⁰

The study used a mixed-method research design,^31–34 and collected data using an online survey portal³⁵ reported in accordance with mixed-methods reporting guidelines.³⁶ The theoretical framework of the study was a convergent mixed-methods design within an advocacy/participatory construct.³⁷ This design was used since this type of research facilitates an action agenda for reform by providing a voice for participants.³⁸ The survey was emailed to practicing Australian chiropractors who were members of the Australian Chiropractic Research Network (ACORN), a practice-based research network (PBRN) database (n=1680) and to academic/researchers employed at the four Australian university-based chiropractic programs (n=220) in early 2019.

A small number of organizations were identified in 2019 that support and fund research on chiropractic topics in Australia. Not all publish official research agendas, strategies, and priorities. The team accessed annual company returns lodged with the Australian Charities and Not-for-profits Commission (ACNC) to cross-check public records against website claims. This was done to try to quantify the aggregated financial contribution of the profession to its own research in Australia, since the team already knew a significant proportion of funding is generated from within the profession.³⁹

The study was approved by the Human Research Ethics Committee of the University of South Australia (UniSA Ethics Protocol #0000035553). Participants were informed about the study via the survey cover sheet. Informed consent was provided by entering the portal and completing the survey.

Results

A series of 4 papers detailing both the quantitative and qualitative results of the survey have been published.^40–43 The response rate from full time equivalent (FTE) academics (n=18/41) was 44%, for casual and part-time chiropractic academics (n=15/179) 8%, and ACORN database chiropractic practitioners (n=340/1580) 21.5%. There are many areas of broad agreement; however, disagreement was identified between academics, researchers, and between and among practitioners with respect to some priorities for future research topics and perspectives on key elements driving research decision-making.

Funders of Australian Research on Chiropractic Topics

The Australian Chiropractors Association (ACA) was confirmed as the largest funder of capacity building and research in the Australian chiropractic profession. ACA funds chiropractic tertiary education, postgraduate and undergraduate scholarships, and research projects in Australia, having provided over $AUD3.3 million between 2009-2022.⁴⁴ Another significant funder is the Australian Spinal Research Foundation (ASRF). Over the 45 years of its existence, the ASRF has funded over 250 projects worth in excess of AUD$2.9 million with almost AUD$900,000 between 2008-2022.⁴⁵ According to ACNC returns, Chiropractic Australia (CA) through its Research Foundation (CARF)³⁹ between 2008-2022 funded $AUD 364,218.³⁰

Of these organizations, the ACA published a detailed Research Summary and Strategic Research Opportunities in 2016,⁴⁶ ASRF published a formal research agenda,⁴⁷and CA has outlined a high-level description of research goals and general aspirational statements.⁴⁸ ACA and ASRF update details of the research they fund in annual reports, newsletters and media releases.

Respondents identified other stakeholders they considered as funders of research being special interest groups, CPD providers and alumni organizations, some of whom have already funded ad hoc and smaller projects.⁴²

Capacity and Output

Research on topics of relevance to the chiropractic profession has value in the context of the public health landscape given the features of the burden of disease among people who consult chiropractors.^49,50 However, the average publication rate per year for Australian chiropractic academics in the PubMed database a decade ago (2013) was found to be low when compared to other health disciplines and has not measurably improved in the interim.^51,52

Until this study the publication activity for chiropractic field practitioners in Australia has been unresearched and unquantified. There exists very little data on the publication activities of ‘field’ practitioners outside the chiropractic profession. One study by Oyibo concluded junior doctors feel that involvement in medical article publishing contributes to learning and education and is an effective method of teaching which supports the need to incorporate such training into their education and training programs.⁵³ However, we were not able to identify any other studies that describe the scholarly publication activity of field practitioners in health professions.

In our study, around 9% of chiropractic field practitioners reported publishing a scientific paper, in the previous 5 years, mainly case reports; thus, it is unclear how this compares to clinicians in other professions. This would appear to be a potential resource that could be accessed to facilitate increased future output, possibly in collaboration with unpublished and underperforming academics. Participation in formal research by practitioners could improve overall capacity and open pathways other than clinical practice for the ‘clinician researcher’.⁵⁴

Recently a new ‘hub’ for post-graduate doctoral research by chiropractors at Southern Cross University (SCU) has emerged which does not currently have a chiropractic program (it does have osteopathy). It remains to be seen if this significantly improves the output of chiropractic doctoral candidates in Australia in the long term.⁵⁵

Journals, Conferences and Symposia

Passionately-held views by academics, and some practitioners, were noted toward ‘organization supported’ journals reflecting personal allegiances and memberships, views which in my anecdotal experience can sometimes manifest in peer-review. Currently Australia has 2 journals supported by member organizations, The Chiropractic Journal of Australia⁵⁶ (Scimago Quartile 4, published by ACA) and Chiropractic & Manual Therapies (CMT) (Scimago Quartile 1, and Medline listed published by CA). CMT is published by BMC Springer/Nature in collaboration with the European Academy of Chiropractic (EAC), the Danish Chiropractic Knowledge Hub - Kiropraktorernes Videnscenter, and the Royal College of Chiropractors (UK).⁵⁷ Recently, the Asia-Pacific Chiropractic Journal, not aligned with a membership organization, has appeared in the region, describing itself as a ‘friendly home of chiropractic clinical science for the world’s quiet Chiropractors’.⁵⁸

Both membership organizations conduct annual scientific conferences and symposia. Some respondents reflected on the challenges of motivating practitioners to attend these events in their current forms.⁴²

Discussion

The organizations and networks described in the introduction of the paper are just a regional sample of those representing, educating, and regulating chiropractors across the globe and it not the intention to provide a complete list. The objective is to present a précis of the main stakeholders it would be advantageous to link.

There have been multiple chiropractic PBRN initiatives that have emerged around the world in the last 30 years. Most have languished, mainly due to proving financially^11,12 or logistically unsustainable.⁷ The future profession will need to plan creatively to avoid projects either failing to launch or not progressing beyond the initial phases of planning and piloting.

This project was conducted as an unfunded sub-study within the ACORN-PBRN. ACORN was initially funded by the Chiropractors Association of Australia (CAA was renamed as the Australian Chiropractors Association-ACA). ACORN was operationalized independently by the Australian Research Consortium in Complementary and Integrative Medicine (ARCCIM) based at the University of Technology Sydney (UTS). The ACORN-PBRN project continued producing legacy publications even after the cessation of funding in 2016, albeit in a diminished capacity, generating over 25 peer-reviewed publications. There were also multiple scientific conference presentations that covered a broad range of topics that served to describe many baseline characteristics of the profession and people who consult chiropractors in Australia.^{12,30,40–42,50,59–71} The cessation in funding by ACA resulted in the project being suspended although the database is still held at UTS and could presumably be rejuvenated if funding were to be renewed.

While collating data for this study it was challenging to locate credible, searchable sources to allow triangulation and verification, for example, of research publication output and grant funding secured by academic researchers. It was not even possible to collate contemporaneous, complete lists of all Australian chiropractic academics and researchers regarding their output, funding, and expertise as not all are listed on publicly available university staff portals and may possibly be considered ‘commercial in confidence.’ The team relied on heads of programs to circulate our survey, which precluded contacting potential academic and researcher participants directly. This may have limited the response rate we received, especially from supervising clinicians, casual and part-time academics. The study also collected self-reports of publication output and funding secured from both academics and practitioners. These factors limit the generalization of the findings. Prior to our study, there was not even a public list of Australian chiropractors with a PhD. A list compiled by the author was provided to the ACA and has since been updated by the Australian Chiropractors Education and Research Fund (ACERF) committee. Clearly, to be able to access a central database that recorded these details would negate the need to triangulate different sources for verification, for example, when seeking peer-review of funding applications.

While our previous papers recommended convening an Australian chiropractic-related Research Agenda Conference,^40,41 the challenges inherent in attempting this were recognized and articulated. A more pragmatic, achievable objective would be establishing a chiropractic-focused database register and repository, a virtual chiropractic network and database that may incorporate data or links to all stakeholders in the profession. There exist similar less comprehensive resources in other professions that could inform such a network, for example, in physiotherapy.⁷² A register, compendium, or almanac collating data on the profession, possibly providing some features as open access as a common resource would serve many functions. It is readily apparent such a resource could be commercialized to ensure sustainability.

Such a resource within the chiropractic profession could begin by creating academic and researcher profiles including their publications of all types, and funding secured, including that of ‘clinician researchers’ whose main role is private practice. It could thus serve as an eclectic collegial community, connecting researchers, peer-reviewers, and funders, among many other functions. Resources exist that could be aggregated, adapted, and expanded to include these aspects to reduce duplication and facilitate greater efficiency in the chiropractic research and educational space.^16,17,73

Intuitively, such a resource would appear best developed in collaboration with the World Federation of Chiropractic (WFC). It could be mainly self-funded while logistically supported internationally by member organizations and institutions.⁷⁴ A research register and repository would serve to facilitate connections between individual researchers potentially decreasing duplication and unproductive competition. Existing resources provide models that may be linked such as ACC-RAC,¹⁸ Manual Alternative and Natural Therapy Index System (MANTIS),¹⁶ Chiro.org - Chiropractic Resource Organization¹⁷ and CERF.¹⁵ As the bodies representing chiropractors in Australasia, the ACA, CA, and the New Zealand Chiropractors’ Association (NZCA) are well placed to initiate these initiatives at a regional level, partnering with a willing education institution for modest cost.

We made a series of recommendations for the way forward in previous papers, toward rationalizing and creating efficiencies and addressing duplication of resources in the profession.^40–43 Further research in the form of deeper engagement with each stakeholder group, possibly using qualitative methods including focus groups or Delphi panels, would be needed to delve more deeply into the issues identified in the series. Since there are only a few recognized chiropractic organizations that fund research in Australasia, cooperation, and consensus between these organizations regarding research strategy is desirable, even if unlikely. The overlap in research priorities encountered within the chiropractic profession, considering all stakeholders, should be identified and ear-marked for implementation within the context of the primary care setting of the chiropractic profession. Those academics who are keen to be engaged with meaningful research, and the programs within which they are embedded, could be encouraged to re-distribute their teaching time and other activities to include research activity where there is a proportionate relationship between time and research activity and output.⁴³

In an emerging era of health service task substitution,⁷⁵ chiropractic-related research could facilitate the expansion of chiropractic service delivery in the primary care sector within which the profession functions. Accreditors could facilitate reporting of research output by requiring regular reporting to a central database by institutions as a condition of accreditation.⁷⁶

Conceiving such a network requires creative visualization. Seeing what could be as if it already is. The world-wide chiropractic network already ‘exists’; it just needs formalized structure and rationalization. Such an undertaking requires vision. A vision that it is not just a pipedream to view the entire profession as a kaleidoscope, different facets of a sector focused on improving the lives of people who consult chiropractors and the wider society as a result. Seeing chiropractic as a big profession, consequential and significant.⁷⁷ This does not mean complete unity on all issues; that is a pipedream, a vision that represents recognition and respect for diversity among equal colleagues.

Recently a group of chiropractic thought leaders including myself, reflected on what the chiropractor of the future and what the profession could look like. Common themes were that chiropractors are competent, well-educated experts in spine and musculoskeletal care. They apply evidence-based practices, serve the best interests of their patients, provide person-centered care, and embrace diversity, equity, and inclusion, with a strong professional identity. Chiropractors contribute to the greater good of society and participate on a global level in policy, leadership, and research.⁷⁸ Focusing the professions’ limited resources is a clear and present imperative to realize this collective vision.

In my view, creating a network that links the entire chiropractic profession is an achievable and necessary Idea.

A Functional World-Wide Chiropractic Network

From the inception of the chiropractic profession, there have been divisions and schisms. These factional differences are so well described and recognized it seems redundant to specify them again in detail here. It is needless to observe that these rifts within the profession manifest in every aspect of public and private discourse often characterized by a ‘winner take all’ dynamic with each faction intent on ‘cleansing’ the profession of the other. One could describe the chiropractic professional history as scattered with the emotional skeletons of those who fought to the death to silence and eliminate those with whom they disagreed.⁷⁹ It can therefore be deduced from nearly 130 years of these interminable disagreements, is that it is patently clear that neither will ever destroy the other.

In reality, the personal paradigms of the profession lie more on a continuum and identification and categorization may even depend on context.⁷⁹ It appears thus that rather than expend energy seeking complete uniformity, the profession may be better served to develop tolerance and influence others by setting an example of exemplary professional conduct. The premise of this paper is the creation of an inclusive community, a network where one can access whatever resources they need regardless of their paradigm. One of the striking features of our data was that the profession has more in common than it might realize, at least when it comes to research priorities.

Virtually every aspect of the chiropractic profession reflects the historical differences that characterize the ‘DNA’ of this profession. Practitioners position themselves as straight, mixer, broad scope, science-based, idealist, vitalist, or something in-between. Membership organizations are formed reflecting the polarized paradigms of practitioners, confirmation bias citing evidence that suits cherry picked context is observed across all sectors. Educational institutions are created that reflect these sometimes exclusivist ‘philosophical’ stances. Even regulators and accreditation agencies are often fractured and operate in silos implementing variable scopes of practice and different legislation across jurisdictions.

Some initiatives specifically exclude gathering data from those who do not fit the profile of the group,¹⁰ and other commentary openly canvasses a divorce,⁸⁰ as if the profession were a family. Presumably the proponents of the divorce idea would intend to keep the family name and any ‘assets.’ Any attempts to create this big community network should recognize the futility of excluding disparate sectors of the profession and hope they disappear in time.

The rapid development of the profession outside the Euro-Anglo-centric axis in Africa, Asia and Latin America must also be incorporated and celebrated. Just as the clinical encounter is inherently complex across all systems of medicine, and conventional implementation models are insufficient to meet the needs of real-life clinical practice, so with the chiropractic profession and the space it occupies in healthcare. Complexity science is increasingly being incorporated across all scientific domains as it may better reflect the holistic nature of traditional, complementary, and integrative medicine, and the chiropractic profession should embrace this concept.⁸¹

Building a network will require consideration of the following.

Technological Challenges

There are over 100,000 chiropractors in the world with chiropractic legally recognized in 68 countries.⁸² While it would be a considerable undertaking to connect a significant proportion into linked databases, such a task is achievable in an era where machine learning (ML), and large-language models (LLM) that drive artificial intelligence (AI) are now becoming ubiquitous. Technology now makes it possible to collate large lists and databases from publicly available resources that could be used to provide opt-out or opt-in choices and invitations. Gathering such data from a display through an automatic process is significantly faster and more efficient than collecting data manually.⁸³

It follows that the privacy and cybersecurity issues around such a resource would need to be carefully calibrated and planned in any construction phase including being compliant with privacy legislation, especially in Europe. The General Data Protection Regulation (GDPR) creates a harmonized set of rules for personal data processing in the European Union (EU), to ensure a high level of protection for personal data. While it is an EU law, it imposes obligations on organizations anywhere in the world, provided certain criteria are met.⁸⁴

There exist many internet-based resources that gather publication output, even without participant input; however, none appear dependably accurate or complete.^85–89 Google Scholar for example, is notoriously inaccurate, sometimes erroneously assigning citations to authors with similar names. It is incumbent on the researcher to ensure their profile is accurate in Google Scholar and other portals. Any database that is linked to these online resources would need to be able to remain accurate and up to date. Indeed, the incentive for each individual or entity to ensure the information contained was contemporaneous would be obvious once the resource reached a significant economy of scale, much like Wikipedia articles.⁹⁰

Phased Development

Thus, building such a resource would be phased and regional. Such a database could contain individual and corporate demographic data, a person or entity role in the profession, skill set, interests, research activity such as publications and grants received. Membership of the register could include international practice-based research networks for like-minded clinician-researchers as well as academic researcher networks.

Funders

Given the relative scarcity of research funding available for research on topics of relevance and importance to people who consult chiropractors, a complete record in a database would be valuable, and commercially viable as self-funding. Funders also require robust review panel for grant applications. Locating skilled grant assessors ensures better research design and funding.

Commercial Value

Commercial entities providing goods and services to the profession would have a keen interest in the database and would be clearly identified as funding sources for the financial operation of the resource.

Relationships Between Academics, Researchers, and Educators

Researchers and academics often operate in silos and usually collaborate only with colleagues they know and trust.⁹¹ All require skill sets such as methodologists and statisticians when building project teams or seeking supervision for post-graduate education especially beyond their own institutions. Clearly, access to such a network would extremely useful when recruiting staff. This enhanced accountability and connectivity would facilitate improved post-graduate and continuous professional development (CPD) standards.

Building citation networks from the literature is a valuable method of tracking professional influence. Senzon^91(p89) for example, describes a citation network structure as a pattern of citations demonstrating the influence and count of authors, papers, and journals.⁹² Citation networks are an important way to study an intellectual field,⁹² which includes changes over time and schools of thought. Since knowledge is transported through time along the pathways of the citation network, a citation network is a directed graph tracing the paths of citations from citing to cited papers.⁹³

Senzon illustrated visually the effect relationships can have on publication patterns and the influence individuals and groups can wield on the profession, sometimes effectively directing the scientific discourse via eminence-based medicine.⁹¹ The reality is that researchers on chiropractic topics have very few options when considering where to publish their work with respect to quality journals that have a chiropractic focus. Thus, many look beyond the chiropractic sector for options. It is a matter of conjecture as to the relative pros and cons of this dynamic.

The desirability of introducing researchers to others beyond their immediate sphere of associates may help mitigate the confirmation bias inherent in only publishing with those one has already published, or at the same institution faculty. This network is designed to embrace all academics, researchers, and clinicians regardless of their ‘philosophical paradigm’. This exclusivity is an inherent flaw in any initiative that seeks to recruit only from a particular sector of the profession.¹⁰

Regulators

Regulators and education accreditation councils could have ready access to a network of resources in an easily accessible format that leads to efficiency in cross-checking standards, legal precedent and rights and responsibilities across jurisdictions. Those involved in legal defense and litigation of both individuals and the profession corporately would have ready access to vital materials.

Consumers

Finally, and arguably most importantly, consumers who access chiropractic services, or are considering doing so, would be provided with contemporary information and evidence-informed resources contextualized for their jurisdiction. The best available evidence on any topic with unbiased comparison to other options available to consumers should be readily available to the public. One could envisage the role of consumers functioning as 'The Friends of Chiropractic’, harking back to the public input of inquiries in the past.^94–96 It is readily apparent that consumers who access chiropractic services would be an invaluable recruitment source as a databank of research participants. Creating an international cohort of consumers from which to derive data longitudinally would justify investment even in the absence of any of the other drivers.

Sustainability

Such a collegial network would provide obvious efficiency for anyone seeking robust data related to the chiropractic profession. Curating such a resource would clearly require considerable skills, financial acumen, and, most importantly, motivation and passion. The profession already possesses these attributes which can be harnessed and rationalized.⁴³

Building the network register is one thing, possibly the easiest part, sustaining, curating, and protecting it would be the greater challenge. There are many and varied challenges to the development of such a resource in the current international climate, not the least of which is cybersecurity and privacy constraints. However, we also live in a time of limitless possibilities. There are emerging tools such as large-language models (LLMs) that require robust information to avoid perpetuating incorrect memes and misinformation about the profession. These are merely situations, opportunities, and challenges to be addressed and overcome. The model suggested in this paper includes possible commercialization, thus ensuring self-sustainability. The demise or failure to launch effectively of many of the laudable efforts of the profession thus far can hopefully serve as object lessons for the profession moving forward.

Conclusion

This paper proposes the development of a world-wide chiropractic network incorporating a research register database. Within this virtual community, the proposal is made to link practitioners and practice-based research networks, comprising actively engaged clinician researchers, with academic and researcher networks. Such a database would contain individual and entity demographic data, ones’ role in the profession, skill set, interests, research activity such as publications, and grants received or funded. Such an initiative should incorporate input and reflect the needs and concerns of a wide range of key stakeholders including (but not limited to) practitioners, regulators, educational institutions, CPD providers, accreditors, professional organizations, chiropractic students, and research funders. Ideally also included would be invested stakeholders such as consumers, insurers, third-party payers, health system administrators, and conceivably, government and health departments. Commercialization of the network would be a way of ensuring sustainability. A database of consumers within or linked to the network would allow unprecedented access to a cohort of people who use chiropractic services.

Acknowledgements

LA-W acknowledges the contributions of all co-authors on previous related papers; Jon Adams, Gregory N. Kawchuk, Matthew J. Leach, Barrett E. Losco, Craig S. Moore, Benjamin L. Mullings, Gregory F. Parkin-Smith, Dein Vindigni and Beau L. Woods.

Funding statement

The Australian Chiropractors Association (ACA) formerly known as the Chiropractors’ Association of Australia (CAA) initially funded the ACORN project. However, the funding source of the ACORN project did not influence any aspect of this study. The concepts described in this paper are the responsibility of the author and reflect the independent ideas of the author.

Competing interest statement

LA-W was an ACORN-PBRN Steering Committee Member and is currently deputy chair of the Council on Chiropractic Education Australasia and is currently a committee member of the Australian Chiropractors Education and Research Fund (ACERF).

Data availability

The dataset of this study is available by permission of the author at Harvard University Dataverse.⁹⁷