Chiropractor perceptions and practices regarding interprofessional service delivery in the Danish primary care context

Abstract

For the past 20 years, chiropractors have enjoyed access to the Danish health care system and have been free to build integrated health care delivery partnerships. An electronic survey of chiropractic clinics around Denmark was conducted in order to observe interprofessional practice trends. From the available population of 252 practices, 166 responses were received. Ninety-six percent of respondents considered inter-disciplinary/interprofessional practice to be either “very” or “extremely” important in the context of modern Danish health care. Three occupational groups appear to be commonly involved in practice alongside chiropractors, these being massage therapists (82%), physiotherapists (58%) and acupuncturists (37%). Interestingly only 11% considered a medical practitioner to be an active participant in their current interprofessional service delivery. Danish chiropractors consider interprofessional practice to be important and as a group, perceive themselves to be offering such models of service provision. Medical practitioners are perceived as desirable, but under utilized partners.     

Communication between general practitioners and chiropractors

OBJECTIVE: Good communication between health care professionals has proved to be important in ensuring high standards of care. Patients have shown an increased use of complementary medicine (eg, chiropractic) in addition to conventional medicine. However, this does not automatically guarantee good cooperation and communication between complementary practitioners and conventional practitioners. The objective of this study was to assess the nature and quality of communication between general practitioners and chiropractors (in The Netherlands) and to look for areas for improvement. DESIGN AND SETTING: Postal questionnaires were sent to general practitioners requesting personal and practice details and asking about their knowledge of chiropractic, present communications, opinions on chiropractic terminology, and preferences with regard to communications with patients. SUBJECTS: A total of 252 general practitioners in 84 Dutch cities. RESULTS: A total of 115 questionnaires (46%) were returned. Almost all of the general practitioners had at least heard of chiropractic. Most information came from patients who were treated by chiropractors (78%). Only 10% of the general practitioners refer their patients to a chiropractor on a regular basis. Referral of patients was found to be significantly related to the general practitioners' perceived knowledge of chiropractic and positive opinions regarding their past communications with chiropractors. More than 80% of the general practitioners said that they were interested in receiving (or continuing to receive) feedback reports, even if they did not personally refer the patient to the chiropractor. Chiropractic feedback reports often seem to contain confusing terminology (40%), which might negatively influence communication (66%). General practitioners preferred a typed (88%), short (69%) feedback report, preferably sent after the last treatment (72%). CONCLUSIONS: The results of this study show most general practitioners to have a neutral to positive attitude toward communication with chiropractors. The general practitioners' preferences with regard to the technical aspects of a feedback report concur with the results of similar surveys in the field and can be used as guidelines for written communications. Factors that negatively influence communication between general practitioners and chiropractors seem to be confusing terminology, a limited knowledge of chiropractic, and bad experiences in previous communications. Recognition and illumination of these factors is a prerequisite to the development of good communication.     

Association Between Characteristics of Danish Chiropractors and Number of Referred Patients From General Practitioners: A Cross-sectional Study

ObjectiveThe purposes of this study were to quantify the number of patients referred weekly from primary health care general practitioners (GPs) to chiropractors and to identify chiropractor characteristics associated with the number of referrals.MethodsAn online, cross-sectional survey was sent to the 600 active members of the Danish Chiropractic Association. Of those, 364 completed the survey and 286 met our inclusion criteria. We used bivariable analyses and negative binomial multivariable regression to evaluate the association between predetermined characteristics and the weekly number of patients referred by GPs.ResultsOn average, chiropractors reported that they received 2.5 (standard deviation, 2.2) referrals from GPs per week, representing 31% of all new patients received by chiropractors. Clinics with more than 1 chiropractor and access to diagnostic ultrasound received more GP referrals. Chiropractors reporting expertise in geriatrics and a higher number of new patients per week reported more referrals. Chiropractors who reported referring more patients to GPs also reported receiving more referrals from them.ConclusionVariables related to access to chiropractic care, the type of care provided, and interprofessional communication were positively associated with the number of GP referrals that chiropractors self-reported. This is the first study to report on factors associated with GP referrals to Danish chiropractors.     

Attitudes to back pain amongst musculoskeletal practitioners: a comparison of professional groups and practice settings using the ABS-mp

Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain (LBP) patients in the UK. We investigated the attitudes of these three professional groups to back pain using a recently developed and validated questionnaire, the Attitudes to Back Pain Scale for musculoskeletal practitioners (ABS-mp). A cross-sectional questionnaire survey was sent to 300 of each professional group (n=900). Responses were analysed from 465 practitioners: 132 chiropractors (28%), 159 osteopaths (34%) and 174 physiotherapists (37%). Overall, all three groups endorse a psychosocial approach to treatment, and see re-activation as a primary goal. However, physiotherapists and osteopaths tend to endorse attitudes towards limiting the number of treatment sessions offered to LBP patients more than chiropractors, and chiropractors endorse a more biomedical approach than physiotherapists. When practice setting (NHS versus private practice) was considered (in physiotherapists alone), physiotherapists working for the NHS endorsed limiting the number of treatment sessions more than those working in the private sector and would also less frequently advise their patients to restrict activities and be vigilant. The results may help explain current clinical practice patterns observed in these groups and their uptake of clinical guideline recommendations.     

Who's interested in chiropractic history?

OBJECTIVE: To determine the extent of interest in chiropractic history among chiropractors in various nations, states and provinces. DATA SOURCES: The worldwide chiropractor population distribution was determined by noting the circulation of the biweekly magazine, Dynamic Chiropractic. Interest in chiropractic history among chiropractors was implied by inclusion in the Membership Directory of the Association for the History of Chiropractic (AHC). DATA EXTRACTION: An interest index was derived by expressing the number of members of the AHC as a percentage of the chiropractor population in each region. DATA SYNTHESIS: Worldwide membership in the AHC involves less than 1% of the total estimated chiropractor population; Canadian chiropractors demonstrated twice as much interest proportionately compared to all other members of the profession. CONCLUSIONS: Reasons for the minimal interest in chiropractic history are considered, and recommendations for increasing historical interest and scholarship are provided.     

Exploring how Australian occupational therapists and physiotherapists understand each other’s professional values: implications for interprofessional education and practice

Abstract

This article provides insight into the values Australian occupational therapists and physiotherapists consider essential for their practice and the values that they perceive as important for each other. Findings from a study that employed the Delphi technique to identify the values occupational therapists and physiotherapists consider essential for their practice were compared with interview results that provide insight into how these professionals perceive one another’s values. The results from this comparison indicate that occupational therapy and physiotherapy participants have limited knowledge of each other’s values. This is evidenced by participants only identifying a minority of the values considered essential within the other profession and not identifying many of the values that guide daily practice within the other profession. The results hold implications for interprofessional education and practice, where knowledge of the values of other professions in the team is essential. To enable interprofessional collaboration, professions need to make their values explicit and provide their students, practitioners and educators with opportunities to learn about their own values and the values of other professions.     

Chiropractic's functional integration into conventional health care: some implications

Australian chiropractors have achieved functional integration into a referral network within conventional health care. In order that benefits from this achievement be maximized, one issue that needs to be addressed includes the streamlining of interprofessional referrals. Most respondents indicated that their preferred interprofessional communication pattern within this network was either by telephone or written report. Delineation of chiropractic scope of practice and/or the services available within chiropractic clinics is suggested as a means of further refining the efficiency of interprofessional referrals. Another issue to be addressed is the implementation of a rational approach when chiropractic belief and traditional medical practice are in conflict. As complementary conventional health care practitioners, chiropractors are representatives of the orthodox health care system. This paper proposes a format whereby resolution of conflicts between ascribed and perceived roles may be attempted. Evolutionary progress rather than revolutionary disruption is possible within conventional health care.     

Chiropractic patients in the Netherlands: a descriptive study

BACKGROUND: Despite the worldwide popularity of chiropractic, there is still relatively little known about the patients who visit chiropractors in the Netherlands and other European countries. OBJECTIVE: To describe in-depth the patient population of new patients to chiropractors in the Netherlands. DESIGN: Study population consisted of 10 consecutive new patients per participating chiropractor. A retrospective-type questionnaire was used. SETTING: Private practice. OUTCOME MEASURES: Mode of referral, area, and nature of the complaints; related to the chief complaint: previous treatments, examinations, type of referral, days lost at work, level of pain, and treatment expectations. RESULTS: Of the 130 chiropractors registered with the Netherlands Chiropractors'Association, 94 chiropractors(78%) participated. Eight hundred thirty-three patients (89%) returned questionnaires. By far, the greatest reason that patients visit chiropractors in the Netherlands is for neuromusculoskeletal (NMS) complaints. At the time of examination, 86% of the patients had spinal-related complaints, of which 12% involved multiple areas of the spine. Non-NMS complaints are minimal (<2%). Seventy-seven percent of patients with NMS complaints have chronic complaints (>12 weeks). Three-quarters of these patients have undergone previous conservative therapy for their complaint, which includes physical and manual therapy, postural correction, and exercise therapy. Despite the chronic nature of their complaints, patients have high expectations that their treatment will be effective. CONCLUSIONS: Most patients who see chiropractors in the Netherlands have chronic NMS-related complaints. Chiropractors are not a part of the normal referral system in this country, with the result that the patients have rather long histories, including previous evaluations by medical specialists and other previous forms of (conservative) care.     

General practice and chiropractic in Norway: How well do they communicate and what do GPs want to know?

BACKGROUND: Some within the medical establishment believe that the education and training of chiropractors is grounded in orthodox medicine and that these professional groups share a common language allowing for close dialogue. However, levels of communication and collaboration often remain low. Furthermore, studies have shown chiropractors to be lax in providing written reports to referring clinicians, a practice important to both patient care and interprofessional relationships. OBJECTIVE: To investigate existing levels of communication between general practitioners (GPs) and chiropractors in Norway and to identify trends in GP preferences for future interprofessional communications. DESIGN AND SETTING: A postal survey was conducted on a random sample of 230 GPs in Norway. RESULTS: A response rate of 51% was achieved. All respondents reported having made at least one referral to a chiropractor. Most (63%) referred infrequently, and only 7% communicated often with a chiropractor. Of those who were in contact with a chiropractor, three fourths communicated by telephone. One fifth of the respondents negatively assessed the quality of written reports. Approximately one third of those GPs who had referred patients did not receive a report, despite this being obligatory in Norway. Twelve percent reported problems with terminology. A written report for future reporting was favored by 75% of the GPs, who wanted the report to contain information on examination findings, diagnosis, treatment, and advice given. CONCLUSION: In general, communications between GPs and chiropractors in Norway are not ideal, particularly with regard to frequency and written quality. However, this is not unique to Norway. With increasing emphasis on multidisciplinary health care, greater understanding and better communication is needed to optimize the benefits of such an approach to patient management. Relevant, timely, consistent reporting on a reciprocal basis, together with a shared vocabulary, should help this process.     

Persistent back pain – why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors,osteopaths and physiotherapists

AIMS: (a) To investigate how widespread is the use of long term treatment without improvement amongst clinicians treating individuals with low back pain. (b) To study the beliefs behind the reasons why chiropractors, osteopaths and physiotherapists continue to treat people whose low back pain appears not to be improving. METHODS: A mixed methods study, including a questionnaire survey and qualitative analysis of semi-structured interviews. Questionnaire survey; 354/600 (59%) clinicians equally distributed between chiropractic, osteopathy and physiotherapy professions. Interview study; a purposive sample of fourteen clinicians from each profession identified from the survey responses. Methodological techniques ranged from grounded theory analysis to sorting of categories by both the research team and the subjects themselves. RESULTS: At least 10% of each of the professions reported that they continued to treat patients with low back pain who showed almost no improvement for over three months. There is some indication that this is an underestimate. reasons for continuing unsuccessful management of low back pain were not found to be primarily monetary in nature; rather it appears to have much more to do with the scope of care that extends beyond issues addressed in the current physical therapy guidelines. The interview data showed that clinicians viewed their role as including health education and counselling rather than a 'cure or refer' approach. Additionally, participants raised concerns that discharging patients from their care meant sending them to into a therapeutic void. CONCLUSION: Long-term treatment of patients with low back pain without objective signs of improvement is an established practice in a minority of clinicians studied. This approach contrasts with clinical guidelines that encourage self-management, reassurance, re-activation, and involvement of multidisciplinary teams for patients who do not recover. Some of the rationale provided makes a strong case for ongoing contact. However, the practice is also maintained through poor communication with other professions and mistrust of the healthcare system.     

Nutritional intervention in chiropractic clinical practice: the chiropractic student's perspective

A survey of chiropractic students reveals that they regard chiropractors as a knowledgeable source of information about nutrition. While the dissonance produced by the use of nutrients in clinical practice may be overcome by denying that this constitutes drug therapy, the controversies of appropriate use need to be addressed. The challenge faced by chiropractic undergraduate nutrition education involves identification of justifiable nutritional interventions, selection of effective doses and an awareness of the potential side effects. By resolving to match or better the medical profession as a source of nutritional health care, the future chiropractor has unwittingly embraced the cost-benefit paradigm of medical drug therapy.     

An Investigation of Chiropractor-Directed Weight-Loss Interventions: Secondary Analysis of O-COAST

ObjectiveThe purpose of this study was to investigate weight-loss interventions offered by Canadian doctors of chiropractic to their adult patients.MethodsThis paper reports a secondary analysis of data from the Ontario Chiropractic Observation and Analysis STudy (N_c = 42 chiropractors, N_p = 2162 patient encounters). Multilevel logistic regression was performed to assess the odds of chiropractors initiating or continuing weight management interventions with patients. Two chiropractor variables and 8 patient-level variables were investigated for influence on chiropractor-directed weight management. In addition, the interaction between the effects of patient weight and comorbidity on weight management interventions by chiropractors was assessed.ResultsAround two-thirds (61.3%) of patients who sought chiropractic care were either overweight or had obesity. Very few patients had weight loss managed by their chiropractor. Among patients with body mass index equal to or greater than 18.5 kg/m², guideline recommended weight management was initiated or continued by Ontario chiropractors in only 5.4% of encounters. Chiropractors did not offer weight management interventions at different rates among patients who were of normal weight, overweight, or obese (P value = 0.23). Chiropractors who graduated after 2005 who may have been exposed to reforms in chiropractic education to include public health were significantly more likely to offer weight management than chiropractors who graduated between 1995 and 2005 (odds ratio 0.02; 95% CI [0.00-0.13]) or before 1995 (odds ratio 0.08; 95% CI [0.01-0.42]).ConclusionThe prevalence of weight management interventions offered to patients by Canadian chiropractors in Ontario was low. Health care policy and continued chiropractic educational reforms may provide further direction to improve weight-loss interventions offered by doctors of chiropractic to their patients.     

Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Abstract

Use of manual therapy in the form of manipulation and massage is evident in the earliest recordings of history. Today, manual therapy is an evidence-based practice that can be used with predictable results in the treatment of a variety of neuromusculoskeletal problems. However, for some manual therapists, treatment is still based on a belief system that incorporates vitalism, energy healing, and other metaphysical concepts. Cooperation of practitioners in researching the effects of manual therapy would require uniformity based upon the guidelines of science, following rules for selection of an evidence-based therapy that produces predictable and replicable results. Such an approach would not allow contamination by dogma or by an agenda that is designed more to support a belief system than to find the truth. The chiropractic profession, which began with a founding father in 1895, is identified primarily by its use of manipulation. But chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words "manipulation" and "subluxation" in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial dislocation or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic "spinal lesion" that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is "adjusted" by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/ mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias.     

Science in chiropractic clinical practice: identifying a need

The chiropractic profession has resolved to establish chiropractic clinical care upon a scientifically acceptable foundation. In order for such an ambition to be realized, the cooperation and participation of field practitioners is required. A survey of chiropractors practicing in Australia demonstrated that respondents largely failed to appreciate the power of various research designs to provide clinical practice information. This paper suggests the chasm between professional resolve and clinical practice is not being adequately bridged at the level of field practitioners.     

Department of law and ethics

A federal district judge, Susan Getzendanner, has found twice against the AMA: First, she found that the group had “engaged in a conspiracy to contain and eliminate the chiropractic profession.” Second, she found that the AMA had been “restricting, regulating or impeding its members from associating with chiropractors.” She issued a permanent injunction against the AMA's doing this. The AMA is now required to say that it is ethical for a physician to associate with a chiropractor if it is in the best interests of the patient. In part, this is unnecessary, since this has been the policy of the AMA since 1980. The AMA will appeal (1).     

Department of law and ethics

Abstract

A federal district judge, Susan Getzendanner, has found twice against the AMA: First, she found that the group had “engaged in a conspiracy to contain and eliminate the chiropractic profession.” Second, she found that the AMA had been “restricting, regulating or impeding its members from associating with chiropractors.” She issued a permanent injunction against the AMA's doing this. The AMA is now required to say that it is ethical for a physician to associate with a chiropractor if it is in the best interests of the patient. In part, this is unnecessary, since this has been the policy of the AMA since 1980. The AMA will appeal (1).     

Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic,osteopathy and physiotherapy professional associations

Trials of manipulative treatment have been compromised by, amongst other things, different definitions of the therapeutic procedures involved. This paper describes a spinal manipulation package agreed by the UK professional bodies that represent chiropractors, osteopaths and physiotherapists. It was devised for use in the UK Back pain Exercise And Manipulation (UK BEAM) trial--a national study of physical treatments in primary care funded by the Medical Research Council and the National Health Service Research and Development Programme. Although systematic reviews have reported some beneficial effects of spinal manipulation for low-back pain, due to the limited methodological quality of primary studies and difficulties in defining manipulation, important questions have remained unanswered. The UK BEAM trial was designed to answer some of those questions. Early in the design of the trial, it was acknowledged that the spinal manipulation treatment regimes provided by practitioners from the three professions shared more similarities than differences. Because the trial design specifically precluded comparison of the effect between the professions, it was necessary to devise a homogenous package representative of, and acceptable to, all three. The resulting package is 'pragmatic', in that it represents what happens to most people undergoing manipulation, and 'explanatory' in that it excludes discipline-specific variations and other ancillary treatments.