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LAY SUMMARYMedical cannabis is increasingly used by Canadian Veterans to manage chronic pain; however, the benefits and harms are uncertain. This commentary summarizes a recent guideline that found small to very small benefits of medical cannabis for pain relief, physical functioning and sleep quality, and evidence for a small to very small increase in several transient harms. The close balance between benefits and harms supports shared decision-making with Veterans living with chronic pain to ensure the decision whether to pursue a trial of medical cannabis is consistent with their values and preferences.

BACKGROUND: The Government of Canada legalized nonmedical use of cannabis in October 2018. Our objectives were to determine the percentage of Canadians intending to try or increase their cannabis use following legalization and to explore characteristics associated with this intent. METHODS: We used data from the 2018 National Cannabis Survey and constructed multivariable regression models. Respondents' data were weighted and bootstrapped. We report relative measures of association as adjusted odds ratios (ORs) and absolute measures of association as adjusted risk increases (RIs). RESULTS: Among the 39 000 households selected for recruitment for the survey, 17 089 respondents provided complete data (43.8%) and our weighted analysis represented 27 808 081 Canadians aged 15 years and older. An estimated 18.5% of respondents (95% confidence interval [CI] 17.6%–19.5%) indicated they intended to try or increase cannabis use following legalization. Being more likely to try or increase cannabis use was associated with younger age (15–24 yr v. ≥ 65 yr; adjusted OR 3.8, 95% CI 2.6–5.6; adjusted RI 20.1%, 95% CI 13.9%–26.2%), cannabis use in the past 3 months versus no use (adjusted OR 3.3, 95% CI 2.8–3.9; adjusted RI 20.4%, 95% CI 17.1%–23.6%), higher income (≥ $80 000 v. < $40 000; adjusted OR 1.5, 95% CI 1.3–1.9; adjusted RI 6.1%, 95% CI 3.2%–9.0%) and poor or fair mental health versus good to excellent mental health (adjusted OR 2.0, 95% CI 1.6–2.6; adjusted RI 11.5%, 95% CI 6.7%–16.2%). INTERPRETATION: Nearly 1 in 5 respondents reported that they intended to try or increase cannabis use after legalization; however, intention may not translate into behaviour. Continued monitoring should help to establish rates and patterns of cannabis use among Canadians following legalization.

LAY SUMMARY In 2020, the Canadian Federal Government launched the Chronic Pain Centre of Excellence for Canadian Veterans (CPCoE). A higher proportion of Veterans experience chronic pain than the general population and the Centre wanted to understand what research topics Veterans thought the new Centre should prioritize. One-on-one interviews were conducted with 11 Canadian Veterans living with chronic pain from five provinces. Eight priority areas for future research were determined: 1) pain care in the military, 2) postoperative care in the military, 3) coordination of services through Veterans Affairs Canada, 4) military-to-civilian transition, 5) primary care provider access outside the military, 6) knowledge of pain management among civilian health care providers, 7) engaging Veterans as partners in their care, and 8) identifying effective strategies for chronic pain management. These findings will help guide research efforts of the new CPCoE.

LAY SUMMARY Patients are more willing to accept treatments that match their preferences. The authors conducted a survey to find out what treatments military Veterans prefer for low back pain. The survey, which asked about experiences with low back pain and attitudes toward health care providers and treatments, reached 1,632 Canadian Armed Forces (CAF) Veterans, and 290 with chronic low back pain completed it. Most respondents said they had lived with low back pain for five or more years. A total of 91% began experiencing pain during military service. The health care providers most preferred to treat chronic low back pain were massage therapists, physiotherapists, family physicians, and chiropractors. Preferences were based on how well treatments worked, how much Veterans trusted the provider, and how accessible the care was. Most respondents said registered massage therapy, physiotherapy, chiropractic, and occupational therapy should be available on military bases for actively serving members of the CAF. Findings about the treatment preferences of military personnel should inform future research and policies to improve management of low back pain among serving CAF members and Veterans.

Background: A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. Objectives: We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. Global summit: The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. Systematic review of the literature: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. Results: We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. Conclusion: Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Abstract Background A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. Objectives We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. Global summit The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. Systematic review of the literature We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. Results We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. Conclusion Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Background: In the midst of the coronavirus pandemic, the International Chiropractors Association (ICA) posted reports claiming that chiropractic care can impact the immune system. These claims clash with recommendations from the World Health Organization and World Federation of Chiropractic. We discuss the scientific validity of the claims made in these ICA reports. Main body: We reviewed the two reports posted by the ICA on their website on March 20 and March 28, 2020. We explored the method used to develop the claim that chiropractic adjustments impact the immune system and discuss the scientific merit of that claim. We provide a response to the ICA reports and explain why this claim lacks scientific credibility and is dangerous to the public. More than 150 researchers from 11 countries reviewed and endorsed our response. Conclusion: In their reports, the ICA provided no valid clinical scientific evidence that chiropractic care can impact the immune system. We call on regulatory authorities and professional leaders to take robust political and regulatory action against those claiming that chiropractic adjustments have a clinical impact on the immune system.