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Tanner L, Saywell NL, Adams T, Niazi IK, Hill J. Factors influencing imaging clinical decision-making in low back pain management. A scoping review. Musculoskeletal Care 2024; 22:e1898. [PMID: 38862275 DOI: 10.1002/msc.1898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process. AIM Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management. DESIGN Scoping review. METHOD This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories. RESULTS After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors. CONCLUSIONS The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour.
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Affiliation(s)
- Luke Tanner
- Clinical Physiotherapist, Auckland, New Zealand
| | - Nicola L Saywell
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
| | - Thomas Adams
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Imran Khan Niazi
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
| | - Julia Hill
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
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van der Vossen B, de Zoete A, Rubinstein S, Ostelo R, de Boer M. Is the use of diagnostic imaging and the self-reported clinical management of low back pain patients influenced by the attitudes and beliefs of chiropractors? A survey of chiropractors in the Netherlands and Belgium. Chiropr Man Therap 2024; 32:1. [PMID: 38191460 PMCID: PMC10775452 DOI: 10.1186/s12998-023-00523-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/07/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND No previous studies have examined the association between attitudes and beliefs of chiropractors and their adherence to low back pain (LBP) guidelines. The aim of this study is: (1) to assess the attitudes and beliefs towards the management of LBP of Dutch and Belgian chiropractors; and (2) to investigate the association of these attitudes and beliefs on the use of diagnostic imaging and on the adherence to diagnostic guidelines and guidelines in the management of patients with LBP. METHODS STUDY DESIGN: Cross-sectional study using a web-based questionnaire in chiropractic private practices in the Netherlands and Belgium. The survey included sociodemographic characteristics, use of diagnostic imaging, the Pain Attitude and Beliefs Scale-Physiotherapists (PABS.PT) and 6 vignettes (3 acute and 3 chronic LBP patients). We used Latent Profile Analysis (LPA) to categorise the chiropractors into clusters depending on their PABS.PT outcome, whereby the classes differed primarily on the biomedical score. We used linear, logistic, and mixed models to examine the associations between these clusters, and adherence to the recommendations of guidelines on: (1) diagnostic imaging use, and (2) management of LBP (i.e. advice on activity, treatment, return-to-work, and bedrest). RESULTS The response rate of the Dutch and Belgian chiropractors was 61% (n = 149/245) and 57% (n = 54/95), respectively. The majority of chiropractors scored midrange of the biomedical scale of the PABS.PT. Three clusters were identified using LPA: (1) high biomedical class (n = 18), (2) mid biomedical class (n = 117) and (3) low biomedical class (n = 23). Results from the vignettes suggest that chiropractors in the high biomedical class better adhere to diagnostic imaging guidelines and to LBP guidelines when it concerns advice on return-to-work and activity compared to the other two classes. However, no differences were identified between the classes for treatment of LBP. All chiropractors adhered to the guidelines' recommendation on bedrest. CONCLUSION The high biomedical class demonstrated better overall adherence to the practice guidelines for the management of LBP and diagnostic imaging than the other classes. Due to the small numbers for the high and low biomedical classes, these results should be interpreted with caution.
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Affiliation(s)
- Brenda van der Vossen
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences Research Institute Amsterdam, Amsterdam, The Netherlands.
| | - Annemarie de Zoete
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences Research Institute Amsterdam, Amsterdam, The Netherlands
| | - Sidney Rubinstein
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences Research Institute Amsterdam, Amsterdam, The Netherlands
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences Research Institute Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Michiel de Boer
- Department of Primary- and Long-Term Care, UMCG, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
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Cupler ZA, Gliedt JA, Perle SM, Puhl AA, Schneider MJ. Associations between demographics and clinical ideology, beliefs, and practice patterns: a secondary analysis of a survey of randomly sampled United States chiropractors. BMC Complement Med Ther 2023; 23:404. [PMID: 37946159 PMCID: PMC10634061 DOI: 10.1186/s12906-023-04225-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The chiropractic profession in the United States (US) has a long history of intra-professional discourse surrounding ideology and beliefs. Large-scale efforts have evaluated 3 distinctive subgroups of US chiropractors focused on these areas of practice: spine/neuromusculoskeletal, primary care, and vertebral subluxation. To our knowledge, there have not been any prior studies exploring the factors associated with these ideology and belief characteristics of these subgroups. The purpose of this study was to explore, describe, and characterize the association of US chiropractors' ideology, beliefs, and practice patterns with: 1) chiropractic degree program of graduation, 2) years since completion of chiropractic degree, and 3) US geographic region of primary practice. METHODS This was a secondary analysis of a cross-sectional survey of a random sample of US licensed chiropractors (n = 8975). A 10% random sample was extracted from each of the 50 states and District of Columbia chiropractic regulatory board lists. The survey was conducted between March 2018-January 2020. The survey instrument consisted of 7 items that were developed to elicit these differentiating ideologies, beliefs, and practice patterns: 1) clinical examination/assessment, 2) health conditions treated, 3) role of chiropractors in the healthcare system, 4) the impact of chiropractic adjustments [spinal manipulation] in treating patients with cancer, 5) vaccination attitudes, 6) detection of subluxation on x-ray, and 7) x-ray utilization rates. Multinomial regression was used to analyze associations between these 7 ideology and practice characteristic items from the survey (dependent variables) and the 3 demographic items listed above (independent variables). RESULTS Data from 3538 respondents (74.6% male) were collected with an overall response rate of 39.4%. Patterns of responses to the 7 survey items for ideologies, beliefs, and practice characteristics were significantly different based on chiropractic degree program of graduation, years since completion of chiropractic degree, and geographic region of primary practice. CONCLUSIONS Among US chiropractors, chiropractic program of graduation, years since completion of chiropractic degree, and geographic region of primary practice are associated with variations in clinical ideology, beliefs, and practice patterns. The wide variation and inconsistent beliefs of US chiropractors could result in public confusion and impede interprofessional integration.
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Affiliation(s)
- Zachary A Cupler
- Butler VA Health Care System, Butler, PA, USA.
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Jordan A Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Stephen M Perle
- Big Data Interrogation Group, AECC University College, Bournemouth, Dorset, UK
- Discipline of Chiropractic, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
| | - Aaron A Puhl
- Private Practice, Able Body Health Clinic, Lethbridge, AB, Canada
| | - Michael J Schneider
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
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de Zoete A, de Boer MR, van Tulder MW, Rubinstein SM, Ostelo R. Diagnostic Imaging in Chiropractic Practice: A Survey of Opinions and Self-Reported Guideline Adherence of Dutch and Belgian Chiropractors. J Manipulative Physiol Ther 2022; 45:57-72. [PMID: 35753875 DOI: 10.1016/j.jmpt.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 02/23/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The purpose of this study was (1) to describe diagnostic imaging in Dutch and Belgian chiropractic practice in general, (2) to estimate adherence to the diagnostic imaging guidelines for patients with low back pain (LBP) via vignettes, and (3) to evaluate factors associated with diagnostic imaging and adherence to the guidelines. METHODS We used a web-based survey to collect sociodemographic data, practice characteristics, amount of imaging, opinions, and indications for requesting imaging from registered Dutch and Belgian chiropractors in 2013. Additionally, adherence to imaging guidelines for LBP was assessed by 6 vignettes in patients with LBP. Multivariable regression analyses were conducted to explore associations between characteristics of chiropractors and the use of imaging. Generalized mixed models were used to explore guidelines adherence and their relationship with chiropractor's characteristics. RESULTS The overall response rate was 60% (n = 203 out of 340). In total, 83% of chiropractors viewed diagnostic imaging in general as an important part of their practice. It is important to note that Dutch and Belgian chiropractors are not allowed to refer directly for imaging. Chiropractors reported that they would like to have imaging in 42% of their patients. Imaging had already been performed in 37% of patients before the first visit and was ordered by another health care provider (ie, general practitioner or medical specialist). The most common indication for ordering imaging was exclusion of contraindications (73%). The most common reason against imaging was the perceived limited value (45%). Many chiropractors (71%) were familiar with imaging guidelines. Adherence to the imaging guidelines for LBP based upon the vignettes was 66%. Dutch chiropractors and chiropractors with less than 10 years in practice demonstrated better adherence to guidelines and imaging use as compared with Belgian and those with more than 10 years of experience. CONCLUSIONS Most Dutch and Belgian chiropractors reported that imaging in general was important in chiropractic practice. Self-reported indications for ordering diagnostic imaging were in line with the imaging guidelines in the majority of cases. We found some variances between Belgian and Dutch chiropractors and years of experience related to guideline adherence.
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Affiliation(s)
- Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Michiel R de Boer
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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Readford TR, Hayes M, Reed WM. Factors affecting chiropractor requests for full-length spinal radiography: A scoping review. J Med Radiat Sci 2022; 69:236-249. [PMID: 34995416 PMCID: PMC9163483 DOI: 10.1002/jmrs.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 12/03/2022] Open
Abstract
Chiropractors often refer their patients for full-length (three- to four-region) radiographs of the spine as part of their clinical assessment, which are frequently completed by radiographers in medical imaging practices. Overuse of spinal radiography by chiropractors has previously been reported and remains a contentious issue. The purpose of this scoping review was to explore the issues surrounding the utilisation of full-length spinal radiography by chiropractors and examine the alignment of this practice with current evidence. A search of four databases (AMED, EMBASE, MedLine and Scopus) and a hand search of Google was conducted using keywords. Articles were screened against an inclusion/exclusion criterion for relevance. Themes and findings were extracted from eligible articles, and evidence was synthesised using a narrative approach. In total, 25 articles were identified, five major themes were extracted, and subsequent conclusions drawn by authors were charted to identify confluent findings. This review identified a paucity of literature addressing this issue and an underrepresentation of relevant perspectives from radiographers. Several issues surrounding the use of full-length spinal radiography by chiropractors were identified and examined, including barriers to the adherence of published guidelines for spinal imaging, an absence of a reporting mechanism for the utilisation of spinal radiography in chiropractic and the existence of a spectrum of beliefs amongst chiropractors about the clinical utility and limitations of full-length spinal radiography. Further investigation is required to further understand the scope of this issue and its impacts for radiation protection and patient safety.
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Affiliation(s)
- Thomas R. Readford
- Discipline of Medical Imaging Science, Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneyCamperdownNew South WalesAustralia
| | - Melanie Hayes
- Discipline of Work Integrated Learning, Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneyCamperdownNew South WalesAustralia
| | - Warren Michael Reed
- Medical Imaging Optimisation and Perception Group (MIOPeG), Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneyCamperdownNew South WalesAustralia
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De Carvalho D, Bussières A, French SD, Wade D, Brake-Patten D, O'Keefe L, Elliott B, Budgell K, O'Reilly S, To D, Hall A. Knowledge of and adherence to radiographic guidelines for low back pain: a survey of chiropractors in Newfoundland and Labrador, Canada. Chiropr Man Therap 2021; 29:4. [PMID: 33461555 PMCID: PMC7812732 DOI: 10.1186/s12998-020-00361-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background Low back pain (LBP) rarely requires routine imaging of the lumbar spine in the primary care setting, as serious spinal pathology is rare. Despite evidence-based clinical practice guidelines recommending delaying imaging in the absence of red flags, chiropractors commonly order imaging outside of these guidelines. The purpose of this study was to survey chiropractors to determine the level of knowledge, adherence to, and beliefs about, clinical practice guidelines related to the use of lumbar radiography for LBP in Newfoundland and Labrador (NL), Canada. Methods A cross-sectional survey of chiropractors in NL (n = 69) was conducted between May and June 2018, including questions on demographics, awareness of radiographic guidelines, and beliefs about radiographs for LBP. We assessed behavioural simulation using clinical vignettes to determine levels of adherence to LBP guideline recommendations. Results The response rate was 77% (n = 53). Half of the participants stated they were aware of current radiographic guideline recommendations, and one quarter of participants indicated they did not use guidelines to inform clinical decisions. The majority of participants agreed that x-rays of the lumbar spine are useful for patients with suspected pathology, are indicated when a patient is non-responsive to 4 weeks of conservative treatment for LBP, and when there are neurological signs associated with LBP. However, a small proportion indicated that there is a role for full spine x-rays (~ 21%), x-rays to evaluate patients with acute LBP (~ 13%), and that patient expectations play a role in decision making (4%). Adherence rate to radiographic guidelines measured using clinical vignettes was 75%. Conclusions While many chiropractors in this sample reported being unsure of specific radiographic guidelines, the majority of respondents adhered to guideline recommendations measured using clinical vignettes. Nonetheless, a small proportion still hold beliefs about radiographs for LBP that are discordant with current radiographic guidelines. Future research should aim to determine barriers to guideline uptake in this population in order to design and evaluate tailored knowledge translation strategies to reduce unnecessary LBP imaging. Supplementary Information The online version contains supplementary material available at 10.1186/s12998-020-00361-2.
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Affiliation(s)
- Diana De Carvalho
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada.
| | - André Bussières
- School of Physical and Occupational Therapy, McGill University, Montréal, QC, Canada.,Département chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | - Barbara Elliott
- Patient Engagement Partner, North Bay, ON, Canada.,Faculty of Education and Professional Studies - School of Nursing, Nipissing University, North Bay, ON, Canada
| | | | - Sara O'Reilly
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Daphne To
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
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Corso M, Cancelliere C, Mior S, Kumar V, Smith A, Côté P. The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature. Chiropr Man Therap 2020; 28:33. [PMID: 32641135 PMCID: PMC7346665 DOI: 10.1186/s12998-020-00323-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/24/2020] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION When indicated by signs or symptoms of potentially serious underlying pathology (red flags), chiropractors can use radiographs to inform their diagnosis. In the absence of red flags, the clinical utility of routine or repeat radiographs to assess the structure and function of the spine is controversial. OBJECTIVES To determine the diagnostic and therapeutic utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. Investigate whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. The research objectives required that we determine the validity, diagnostic accuracy and reliability of radiographs for the structural and functional evaluation of the spine. EVIDENCE REVIEW We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from inception to November 25, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (cross-sectional, case-control, cohort, randomized controlled trials, diagnostic and reliability) were critically appraised. Studies of acceptable quality were included in our synthesis. The lead author extracted data and a second reviewer independently validated the data extraction. We conducted a qualitative synthesis of the evidence. FINDINGS We identified 959 citations, screened 176 full text articles and critically appraised 23. No relevant studies assessed the clinical utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. No studies investigated whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. Nine low risk of bias studies investigated the validity (n = 2) and reliability (n = 8) of routine or repeat radiographs. These studies provide no evidence of clinical utility. CONCLUSION We found no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients. Given the inherent risks of ionizing radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine.
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Affiliation(s)
- Melissa Corso
- Faculty of Health Sciences, Ontario Tech University and Centre for Disability Prevention and Rehabilitation, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada
| | - Carol Cancelliere
- Faculty of Health Sciences, Ontario Tech University and Centre for Disability Prevention and Rehabilitation, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada
| | - Silvano Mior
- Faculty of Health Sciences, Ontario Tech University and Centre for Disability Prevention and Rehabilitation, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada
- Canadian Memorial Chiropractic College, North York, Ontario, Canada
| | - Varsha Kumar
- Canadian Memorial Chiropractic College, North York, Ontario, Canada
| | - Ali Smith
- Canadian Memorial Chiropractic College, North York, Ontario, Canada
| | - Pierre Côté
- Faculty of Health Sciences, Ontario Tech University and Centre for Disability Prevention and Rehabilitation, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada.
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Adams J, de Luca K, Swain M, Funabashi M, Wong A, Pagé I, Sibbritt D, Peng W. Prevalence and practice characteristics of urban and rural or remote Australian chiropractors: Analysis of a nationally representative sample of 1830 chiropractors. Aust J Rural Health 2019; 27:34-41. [PMID: 30719793 DOI: 10.1111/ajr.12447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To determine the prevalence and clinical management characteristics of chiropractors practising in urban and rural or remote Australia. DESIGN A cross-sectional analysis of the Australian Chiropractic Research Network project data. SETTING Nationally representative sample of registered chiropractors practising in Australia. PARTICIPANTS Chiropractors who participated in the Australian Chiropractic Research Network project and answered a question about practising in urban or rural or remote areas in the practitioner questionnaire. MAIN OUTCOME MEASURE The demographics, practice characteristics and clinical management of chiropractors. RESULTS The majority of chiropractors indicated that they practise in urban areas only, while 22.8% (n = 435) practice in rural or remote areas only and 4.0% (n = 77) practice in both urban and rural or remote areas. Statistically significant predictors of chiropractors who practice in rural or remote areas, as compared to urban areas, included more patient visits per week, practising in more than one location, no imaging facilities on site, often treating degenerative spinal conditions or migraine, often treating people aged over 65 years, frequently treating Aboriginal and Torres Strait Islander people and frequently using biomechanical pelvic blocking or the sacro-occipital technique. CONCLUSION A substantial number of chiropractors practice in rural or remote Australia and these rural or remote-based chiropractors are more likely to treat a wide range of musculoskeletal cases and include an Indigenously diverse group of patients than their urban-located colleagues. Unique practice challenges for rural or remote chiropractors include a higher workload and a lack of diagnostic tools. Chiropractors should be acknowledged and considered within rural or remote health care policy and service provision.
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Affiliation(s)
- Jon Adams
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katie de Luca
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia.,Chiropractic Academy for Research Leadership, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Michael Swain
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia.,Chiropractic Academy for Research Leadership, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Martha Funabashi
- Chiropractic Academy for Research Leadership, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Sydney, New South Wales, Australia.,Collaborative Orthopedic Research, Alberta Health Services, Edmonton, Alberta, Canada
| | - Arnold Wong
- Chiropractic Academy for Research Leadership, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Sydney, New South Wales, Australia.,Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Isabelle Pagé
- Chiropractic Academy for Research Leadership, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Sydney, New South Wales, Australia.,Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - David Sibbritt
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Wenbo Peng
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Jenkins HJ, Downie AS, Moore CS, French SD. Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropr Man Therap 2018; 26:48. [PMID: 30479744 PMCID: PMC6247638 DOI: 10.1186/s12998-018-0217-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/02/2018] [Indexed: 12/26/2022] Open
Abstract
The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
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Affiliation(s)
- Hazel J Jenkins
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Aron S Downie
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Craig S Moore
- 2Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Simon D French
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia.,3School of Rehabilitation Therapy, Queen's University, Kingston, ON Canada
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10
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Funk MF, Frisina-Deyo AJ, Mirtz TA, Perle SM. The prevalence of the term subluxation in chiropractic degree program curricula throughout the world. Chiropr Man Therap 2018; 26:24. [PMID: 29988608 PMCID: PMC6027563 DOI: 10.1186/s12998-018-0191-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/27/2018] [Indexed: 12/31/2022] Open
Abstract
Background The subluxation construct generates debate within and outside the profession. The International Chiropractic Education Collaboration, comprised of 10 chiropractic programs outside of North America, stated they will only teach subluxation in a historical context. This research sought to determine how many chiropractic institutions worldwide still use the term in their curricula and to expand upon the previous work of Mirtz & and Perle. Methods Forty-six chiropractic programs, 18 United States (US) and 28 non-US, were identified from the World Federation of Chiropractic Educational Institutions list. Websites were searched by multiple researchers for curricular information September 2016–September 2017. Some data were not available on line, so email requests were made for additional information. Two institutions provided additional information. The total number of mentions of subluxation in course titles, technique course (Tech) descriptions, principles and practice (PP) descriptions, and other course descriptions were reported separately for US and non-US institutions. Means for each category were calculated. The number of course titles and descriptions using subluxation was divided by the total number of courses for each institution and reported as percentages. Results Means for use of subluxation by US institutions were: Total course titles = .44; Tech = 3.83; PP = 1.50; other = 1.16. For non-US institutions, means were: Total course titles = .07; Tech = .27; PP = .44; other = 0. The mean total number of mentions was 6.94 in US vs. 0.83 in non-US institutions. Similarly, the mean course descriptions was 6.50 in US vs. 0.72 in non-US institutions. Conclusions The term subluxation was found in all but two US course catalogues. The use of subluxation in US courses rose from a mean of 5.53 in 2011 to 6.50 in 2017. US institutions use the term significantly more frequently than non-US. Possible reasons for this were discussed. Unscientific terms and concepts should have no place in modern education, except perhaps in historical context. Unless these outdated concepts are rejected, the chiropractic profession and individual chiropractors will likely continue to face difficulties integrating with established health care systems and attaining cultural authority as experts in conservative neuro-musculoskeletal health care.
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Affiliation(s)
- Matthew F Funk
- 1University of Bridgeport College of Chiropractic, Bridgeport, CT USA
| | | | - Timothy A Mirtz
- 2Department of Secondary and Physical Education, Bethune-Cookman University, Daytona Beach, FL USA
| | - Stephen M Perle
- 1University of Bridgeport College of Chiropractic, Bridgeport, CT USA.,3Discipline of Chiropractic, School of Health Professions, Murdoch University, Murdoch, WA Australia
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French SD, Downie AS, Walker BF. Low back pain: a major global problem for which the chiropractic profession needs to take more care. Chiropr Man Therap 2018; 26:28. [PMID: 29983908 PMCID: PMC6016136 DOI: 10.1186/s12998-018-0199-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/15/2018] [Indexed: 02/28/2023] Open
Abstract
An important series of papers have been published in the Lancet. These papers provide a comprehensive update for the major global problem of low back pain, and the challenges that low back pain presents to healthcare practitioners and policy makers. Chiropractors are well placed to reduce the burden of low back pain, but not all that chiropractors do is supported by robust, contemporary evidence. This commentary summarises the Lancet articles. We also make suggestions for how the chiropractic profession should most effectively help people with low back pain by implementing practices supported by high quality evidence.
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Affiliation(s)
- Simon D French
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, 2109 NSW Australia.,2School of Rehabilitation Therapy, Queen's University, Kingston, ON Canada
| | - Aron S Downie
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, 2109 NSW Australia.,3University of Sydney, Sydney, Australia
| | - Bruce F Walker
- 4School of Health Professions, Murdoch University, Perth, Australia
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12
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Jenkins HJ. Awareness of radiographic guidelines for low back pain: a survey of Australian chiropractors. Chiropr Man Therap 2016; 24:39. [PMID: 27713818 PMCID: PMC5051064 DOI: 10.1186/s12998-016-0118-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 08/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background Chiropractors have been shown to refer for lumbar radiography in clinical scenarios inconsistent with the current clinical guidelines for low back pain. It is unknown whether this is due to lack of adherence with known guidelines or a lack of awareness of relevant guidelines. Therefore, the aim of this study is to determine Australian chiropractors’ awareness of, and reported adherence to, radiographic guidelines for low back pain. Demographic, chiropractic practice and radiographic usage characteristics will be investigated for association with poor guideline adherence. Methods An online survey was distributed to Australian chiropractors from July to September, 2014. Survey questions assessed demographic, chiropractic practice and radiographic usage characteristics, awareness of radiographic guidelines for low back pain and the level of agreement with current guidelines. Results were analysed with descriptive statistics and logistic regression analysis. Results There were 480 surveys completed online. Only 49.6 % (95 % confidence interval (95 % CI): 44.9, 54.4) reported awareness of radiographic guidelines for low back pain. Chiropractors reported a likelihood of referring for radiographs for low back pain: in new patients (47.6 % (95 % CI: 42.9, 52.3)); to confirm biomechanical pathologies (69.0 % (95 % CI: 64.5, 73.1)); to perform biomechanical analysis (37.5 % (95 % CI: 33.1, 42.0)); or to screen for contraindications (39.4 % (95 % CI: 35.0, 44.0)). Chiropractors agreed that radiographs for low back pain could be useful for: acute low back pain (54.0 % (95 % CI: 49.2, 58.7)); screening for contraindications (55.8 % (95 % CI: 51.0, 60.5)); or to confirm diagnosis and direct treatment (61.3 % (95 % CI: 56.5, 65.9)). Poorer adherence to current guidelines was seen if the chiropractor referred to in-house radiographic facilities, practiced a technique other than diversified technique or was unaware or unsure of current radiographic guidelines for low back pain. Conclusion Only 50 % of Australian chiropractors report awareness of current radiographic guidelines for low back pain. A poorer awareness of guidelines is associated with an increase in the reported likelihood of use, and the perceived usefulness of radiographs for low back pain, in clinical situations that fall outside of current guidelines. Therefore, education strategies may help to increase guideline knowledge and compliance. Electronic supplementary material The online version of this article (doi:10.1186/s12998-016-0118-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hazel J Jenkins
- C5C347, Macquarie University, Balaclava Rd, North Ryde, New South Wales 2119 Australia
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Puhl AA, Reinhart CJ, Doan JB, McGregor M, Injeyan HS. Relationship between chiropractic teaching institutions and practice characteristics among Canadian doctors of chiropractic: a random sample survey. J Manipulative Physiol Ther 2014; 37:709-18. [PMID: 25439035 DOI: 10.1016/j.jmpt.2014.09.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 08/03/2014] [Accepted: 08/28/2014] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objectives of this study were to determine if faction membership among Canadian doctors of chiropractic (DCs) is associated with differences in educational program characteristics among English-speaking Canadian and United States chiropractic colleges and to determine if those differences are expressed in terms of surveyed attitudes and behaviors regarding treatment efficacy, radiographic imaging, vaccinations, and interprofessional referrals. This study also aims to identify if educational programs may be a potential source of multiple professional identities. METHODS A randomly selected sample of Canadian DCs, stratified across the English-speaking provinces, was surveyed by mail. Survey items included school of graduation, self-categorization by chiropractic subgroup, perceptions of condition-specific treatment efficacy, use of plain film radiographic imaging, vaccination attitudes/behaviors, and patient referral patterns. Self-categorization by chiropractic subgroup included: the unorthodox faction (associates the chiropractic subluxation as an encumbrance to the expression of health) and the orthodox perspective (associates with musculoskeletal joint dysfunction, public health, and lifestyle concerns). For data analysis, chiropractic schools were divided into 2 groups according to location: English-speaking Canada and the US. The US was further clustered into liberal ("interested in mixing elements of modern and alternative therapies into the practice of chiropractic") and conservative categories ("chiropractors who believe in continuing the traditions of chiropractic"). RESULTS Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. χ(2) Testing revealed significant differences in self-categorized faction membership associated with the clustering of colleges based on ideological viewpoints (χ(2) = 27.06; P = .000). Descriptive results revealed a relationship between school of origin and perceived treatment efficacy, use of radiographic imaging, and vaccination attitudes. No significant differences were found relative to interprofessional referral patterns. CONCLUSION Chiropractic program attended is a significant predictor of orthodox vs unorthodox faction membership and professional practice characteristics for Canadian DCs. This suggests that the current chiropractic education system may contribute to multiple professional identities.
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Affiliation(s)
- Aaron A Puhl
- Chiropractor (Private Practice), Able Body Health Clinic, Lethbridge, AB, Canada
| | - Christine J Reinhart
- Chiropractor (Private Practice), Able Body Health Clinic, Lethbridge, AB, Canada
| | - Jon B Doan
- Associate Professor, Department of Kinesiology and Physical Education, University of Lethbridge, Lethbridge, AB, Canada
| | - Marion McGregor
- Director of Education, Year II, Professor, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - H Stephen Injeyan
- Chair, Department of Pathology and Microbiology, Professor, Canadian Memorial Chiropractic College, Toronto, ON, Canada..
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