Chiropractic and CAM utilization: a descriptive review

Chiropractic Care in a Multidisciplinary Sports Health Care Environment: A Survey of Canadian National Team Athletes

OBJECTIVE

The purpose of this study was to describe the utilization of health team practitioners among national-level athletes and report their injury profile as well as access to and knowledge of chiropractic care.

METHODS

This study was a retrospective analysis of non-identifiable, cross-sectional survey data that were previously collected from members of the AthletesCAN organization who voluntarily completed a web-based, bilingual survey in July or August 2017. The sport of the athlete, number of years on a national team, number and type of injuries, health care practitioners visited, and specific details on chiropractic care were collected. Descriptive statistics were performed to summarize the responses in terms of frequencies and percentages.

RESULTS

There was an 11% response rate (198/1733), with 67 unique sports identified (21 winter sports [50 athletes] and 46 summer sports [148 athletes]). Athletics and swimming were the sports with the most respondents. Fewer than half (43.9%) of the 198 respondents were members of AthletesCAN for 2 to 5 years. Seventy percent reported 1 to 5 injuries over their career, with ankle, low back, and shoulder the most likely body parts affected. A majority of athletes (93.4%) reported visiting multiple practitioners, including medical physicians, physiotherapists, athletic therapists, massage therapists, and chiropractors. Two-thirds (67%) of athletes sought chiropractic treatment, most typically for neck or back pain (81.3%), despite nearly half (45.7%) being unsure about access to chiropractic care.

CONCLUSION

This sample of Canadian national team athletes who experience an injury may seek care from multiple types of health care providers and include chiropractic as part of their approach to health care.

Disparities in chiropractic utilization by race, ethnicity and socioeconomic status: A scoping review of the literature

BACKGROUND

Chiropractic is the largest complementary and alternative medicine profession in the United States, with increasing global growth. A preliminary literature review suggests a lack of widespread diversity of chiropractic patient profiles.

OBJECTIVE

There have been no prior studies to comprehensively integrate the literature on chiropractic utilization rates by race, ethnicity, and socioeconomic status. The purpose of this scoping review is to identify and describe the current state of knowledge of chiropractic utilization by race, ethnicity, education level, employment status, and income and poverty level.

SEARCH STRATEGY

Systematic searches were conducted in PubMed, Ovid MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews, and Index to Chiropractic Literature from inception to May 2021.

INCLUSION CRITERIA

Articles that reported race or ethnicity, education level, employment status, income or poverty level variables and chiropractic utilization rates for adults (≥18 years of age) were eligible for this review.

DATA EXTRACTION AND ANALYSIS

Data extracted from articles were citation information, patient characteristics, race and ethnicity, education level, employment status, income and poverty level, and chiropractic utilization rate. A descriptive numerical summary of included studies is provided. This study provides a qualitative thematic narrative of chiropractic utilization with attention to race and ethnicity, education level, income and poverty level, and employment status.

RESULTS

A total of 69 articles were eligible for review. Most articles were published since 2003 and reported data from study populations in the United States. Of the race, ethnicity and socioeconomic categories that were most commonly reported, chiropractic utilization was the highest for individuals identifying as European American/White/non-Hispanic White/Caucasian (median 20.00%; interquartile range 2.70%-64.60%), those with employment as a main income source (median utilization 78.50%; interquartile range 77.90%-79.10%), individuals with an individual or household/family annual income between $40,001 and $60,000 (median utilization 29.40%; interquartile range 25.15%-33.65%), and individuals with less than or equal to (12 years) high school diploma/general educational development certificate completion (median utilization 30.70%; interquartile range 15.10%-37.00%).

CONCLUSION

This comprehensive review of the literature on chiropractic utilization by race, ethnicity and socioeconomic status indicates differences in chiropractic utilization across diverse racial and ethnic and socioeconomic populations. Heterogeneity existed among definitions of key variables, including race, ethnicity, education level, employment status, and income and poverty level in the included studies, reducing clarity in rates of chiropractic utilization for these populations. Please cite this article as: Gliedt JA, Spector AL, Schneider MJ, Williams J, Young S. Disparities in chiropractic utilization by race, ethnicity and socioeconomic status: a scoping review of the literature. J Integr Med. 2023; Epub ahead of print.

Attitudes towards chiropractic: a repeated cross-sectional survey of Canadian family physicians

BACKGROUND

Many primary care patients receive both medical and chiropractic care; however, interprofessional relations between physicians and chiropractors are often suboptimal which may adversely affect care of shared patients. We surveyed Canadian family physicians in 2010 to explore their attitudes towards chiropractic and re-administered the same survey a decade later to explore for changes in attitudes.

METHODS

A 50-item survey administered to a random sample of Canadian family physicians in 2010, and again in 2019, that inquired about demographic variables, knowledge and use of chiropractic. Imbedded in our survey was a 20-item chiropractic attitude questionnaire (CAQ); scores could range from 0 to 80 with higher scores indicating more positive attitudes toward chiropractic. We constructed a multivariable regression model to explore factors associated with CAQ scores.

RESULTS

Among eligible physicians, 251 of 685 in 2010 (37% response rate) and 162 of 2429 in 2019 (7% response rate) provided a completed survey. Approximately half of respondents (48%) endorsed a positive impression of chiropractic, 27% were uncertain, and 25% held negative views. Most respondents (72%) referred at least some patients for chiropractic care, mainly due to patient request or lack of response to medical care. Most physicians believed that chiropractors provide effective therapy for some musculoskeletal complaints (84%) and disagreed that chiropractic care was beneficial for non-musculoskeletal conditions (77%). The majority agreed that chiropractic care was a useful supplement to conventional care (65%) but most respondents (59%) also indicated that practice diversity among chiropractors presented a barrier to interprofessional collaboration. In our adjusted regression model, attitudes towards chiropractic showed trivial improvement from 2010 to 2019 (0.31 points on the 80-point CAQ; 95%CI 0.001 to 0.62). More negative attitudes were associated with older age (- 1.55 points for each 10-year increment from age 28; 95%CI - 2.67 to - 0.44), belief that adverse events are common with chiropractic care (- 1.41 points; 95% CI - 2.59 to - 0.23) and reported use of the research literature (- 6.04 points; 95% CI - 8.47 to - 3.61) or medical school (- 5.03 points; 95% CI  - 7.89 to - 2.18) as sources of knowledge on chiropractic. More positive attitudes were associated with endorsing a relationship with a specific chiropractor (5.24 points; 95% CI 2.85 to 7.64), family and friends (4.06 points; 95% CI 1.53 to 6.60), or personal treatment experience (4.63 points; 95% CI 2.14 to 7.11) as sources of information regarding chiropractic.

CONCLUSIONS

Although generally positive, Canadian family physicians' attitudes towards chiropractic are diverse, and most physicians felt that practice diversity among chiropractors was a barrier to interprofessional collaboration.

Suicide prevention, public health, and the chiropractic profession: a call to action

BACKGROUND

Suicide is a major public health concern that has wide-reaching implications on individuals, families, and society. Efforts to respond to a public health concern as a portal-of-entry provider can reduce morbidity and mortality of patients. The objective of this commentary is a call to action to initiate dialogue regarding suicide prevention and the role the chiropractic profession may play.

DISCUSSION

This public health burden requires doctors of chiropractic to realize current strengths and recognize contemporaneous deficiencies in clinical, research, and policy environments. With this better understanding, only then can the chiropractic profession strive to enhance knowledge and promote clinical acumen to target and mitigate suicide risk to better serve the public.

CONCLUSION

We implore the profession to transition from bystander to actively engaged in the culture of suicide prevention beholden to all aspects of the biopsychosocial healthcare model. The chiropractic profession's participation in suicide prevention improves the health and wellness of one's community while also impacting the broader public health arena.

Malpractice Litigation Involving Chiropractic Spinal Manipulation

OBJECTIVE

To evaluate the relationship between chiropractic spinal manipulation and medical malpractice using a legal database.

METHODS

The legal database VerdictSearch was queried using the terms "chiropractor" OR "spinal manipulation" under the classification of "Medical Malpractice" between 1988 and 2018. Cases with chiropractors as defendants were identified. Relevant medicolegal characteristics were obtained, including legal outcome (plaintiff/defense verdict, settlement), payment amount, nature of plaintiff claim, and type and location of alleged injury.

RESULTS

Forty-eight cases involving chiropractic management in the United States were reported. Of these, 93.8% (n = 45) featured allegations involving spinal manipulation. The defense (practitioner) was victorious in 70.8% (n = 34) of cases, with a plaintiff (patient) victory in 20.8% (n = 10) (mean payment $658,487 ± $697,045) and settlement in 8.3% (n = 4) (mean payment $596,667 ± $402,534). Overaggressive manipulation was the most frequent allegation (33.3%; 16 cases). A majority of cases alleged neurological injury of the spine as the reason for litigation (66.7%, 32 cases) with 87.5% (28/32) requiring surgery. C5-C6 disc herniation was the most frequently alleged injury (32.4%, 11/34, 83.3% requiring surgery) followed by C6-C7 herniation (26.5%, 9/34, 88.9% requiring surgery). Claims also alleged 7 cases of stroke (14.6%) and 2 rib fractures (4.2%) from manipulation therapy.

CONCLUSIONS

Litigation claims following chiropractic care predominately alleged neurological injury with consequent surgical management. Plaintiffs primarily alleged overaggressive treatment, though a majority of trials ended in defensive verdicts. Ongoing analysis of malpractice provides a unique lens through which to view this complicated topic.

Preliminary Feasibility Study to Measure the Immediate Changes of Bilateral Asymmetry After Lumbar Spinal Manipulative Therapy in Asymptomatic Athletes

Objective

The purpose of this preliminary study was to assess the feasibility of a study to measure the immediate changes in bilateral asymmetry on physical performance tests before and after lumbar spinal manipulative therapy (SMT).

Methods

Thirteen asymptomatic athletes participated in this study. Each participant underwent a clinical and physical evaluation for inclusion according to eligibility criteria. Assessments were performed in all participants and included a physical test symmetry sequence (static standing position, squat, and countermovement jump) before and after lumbar SMT intervention. The immediate changes were quantitatively measured from before to after intervention by statistical calculations.

Results

All recruited participants completed the study, and none of them reported complaints during participation. Statistically significant differences between before and after lumbar SMT were found only for static symmetry (respectively, mean = 14.4% and 3.7%), not for squatting or the countermovement jump.

Conclusion

According our sample characteristics, asymptomatic athlete participants, presented initially bilateral asymmetry values, such as described in the literature, and after lumbar SMT, these values decreased significantly in static posture. This preliminary study demonstrates the feasibility to measure the pre-to-post changes in symmetry after lumbar SMT intervention. The results showed a great decrease in bilateral symmetry on static symmetry percentage, but none in dynamic tests, which deserves further investigation. Nevertheless, this preliminary study demonstrated the feasibility of measuring the immediate changes in symmetry produced by lumbar SMT, and of a larger study to measure whether lumbar SMT changes symmetry.

Chiropractic Utilization Among Patients in Klang Valley, Malaysia

OBJECTIVE

The purpose of this study was to estimate the utilization of chiropractic in Klang Valley, Malaysia.

METHODS

This research was a cross-sectional study conducted in 4 health care centers, namely Klinik Mediviron Sri Rampai, Queck Dental Surgery, International Medical University (IMU) Healthcare Chiropractic Centre, and Be Pharmacy Bandar Sri Permaisuri, in Klang Valley from July to November 2018, with a total of 440 respondents. The data collection was done by the self-administration method using questionnaires that were enclosed in envelopes and passed on to the participants by the center's staff. Descriptive statistics were conducted on the data collected and are presented in tables and figures. The variables were sex, age, nationality, ethnicity, marital status, education level, employment status, and health status with the utilization of chiropractic.

RESULT

There were 186 (42.3%) male and 254 (57.7%) female respondents. The youngest respondent was 18 years old, and the oldest was 81 years old. The median age was 30 years old. Most respondents (97.3%) were Malaysian from a non-Bumiputra (non-Malay) ethnic group. Almost half (47.5%) of the respondents had a bachelor's degree education level. The utilization of chiropractic was 35.9% (95% confidence interval [CI]: 31.4-40.5).

CONCLUSION

The utilization of chiropractic was 35.9%, which was slightly lower than utilization among other traditional and complementary medicine practices in Malaysia.

Vitalism in contemporary chiropractic: a help or a hinderance?

BACKGROUND

Chiropractic emerged in 1895 and was promoted as a viable health care substitute in direct competition with the medical profession. This was an era when there was a belief that one cause and one cure for all disease would be discovered. The chiropractic version was a theory that most diseases were caused by subluxated (slightly displaced) vertebrae interfering with "nerve vibrations" (a supernatural, vital force) and could be cured by adjusting (repositioning) vertebrae, thereby removing the interference with the body's inherent capacity to heal. DD Palmer, the originator of chiropractic, established chiropractic based on vitalistic principles. Anecdotally, the authors have observed that many chiropractors who overtly claim to be "vitalists" cannot define the term. Therefore, we sought the origins of vitalism and to examine its effects on chiropractic today.

DISCUSSION

Vitalism arose out of human curiosity around the biggest questions: Where do we come from? What is life? For some, life was derived from an unknown and unknowable vital force. For others, a vital force was a placeholder, a piece of knowledge not yet grasped but attainable. Developments in science have demonstrated there is no longer a need to invoke vitalistic entities as either explanations or hypotheses for biological phenomena. Nevertheless, vitalism remains within chiropractic. In this examination of vitalism within chiropractic we explore the history of vitalism, vitalism within chiropractic and whether a vitalistic ideology is compatible with the legal and ethical requirements for registered health care professionals such as chiropractors.

CONCLUSION

Vitalism has had many meanings throughout the centuries of recorded history. Though only vaguely defined by chiropractors, vitalism, as a representation of supernatural force and therefore an untestable hypothesis, sits at the heart of the divisions within chiropractic and acts as an impediment to chiropractic legitimacy, cultural authority and integration into mainstream health care.

Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Background

Recent clinical practice guidelines for the management of non-specific low back pain (LBP) recommend using stratified care approaches. To date, no study has assessed barriers and facilitators for health professionals in using stratified care approaches for managing non-specific LBP in the Canadian primary care setting. This study aimed to identify and contrast barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors.

Methods

Individual telephone interviews, underpinned by the Theoretical Domains Framework (TDF), explored beliefs and attitudes about, and identified barriers and facilitators to the use of stratified care approaches for managing non-specific LBP in a purposive sample of 13 chiropractors and 14 physiotherapists between September 2015 and June 2016. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using directed content analysis.

Results

Three and seven TDF domains were identified as likely relevant for physiotherapists and chiropractors, respectively. Shared key beliefs (and relevant domains of the TDF) for both physiotherapists and chiropractors included: lack of time, cost, and expertise (Environmental Context and Resources); and consulting more experienced colleagues and chronic patients with important psychological overlay (Social Influences). Unique key domains were identified among physiotherapists: incompatibility with achieving other objectives (Goals), and chiropractors: confidence in using stratified care approaches (Beliefs about Capabilities); intention to use stratified care approaches (Intentions); awareness and agreement with stratified care approaches (Knowledge); assessment of readiness for change and intentional planning behaviour (Behavioural Regulation); and improving the management of non-specific LBP patients and the uptake of evidence-based practice (Beliefs about Consequences).

Conclusions

Several shared and unique barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors were identified. Findings may help inform the design of tailored theory-based knowledge translation interventions to increase the uptake of stratified care approaches in clinical practice.

Molecular foundations of chiropractic therapy

Background and aim: Alternative medicine is a broad term used to encompass different therapies, including chiropractic. Chiropractic was called “a science of healing without drugs” by its founder, David Daniel Palmer. It is based on the idea that the body has a powerful self-healing ability and that there is a relationship between body structure and function that affects health. In particular, chiropractic assumes that the nervous system controls the human body through nerves branching from the vertebral column and spinal cord. Researchers do not fully understand how chiropractic therapies affect pain, but chiropractic is widely used today to treat chronic pain, such as back pain. Different studies with animal models have demonstrated that chiropractic therapies mediate neuroplasticity, specifically through modulation of neurotrophins. No studies have yet been published on interaction between neurotrophin gene polymorphisms and chiropractic treatment. Methods: We searched PubMed with the following keywords: chiropractic, neuroplasticity, neurotrophin gene polymorphism for a panorama of on the molecular mechanisms of chiropractic therapy. Results: From the material collected, we identified a set of genes and some functional polymorphisms that could be correlated with better response to chiropractic therapy. Conclusions: Further association studies will be necessary to confirm hypotheses of a correlation between single nucleotide polymorphisms in specific genes and better response to chiropractic therapy. (www.actabiomedica.it)

Politics Ahead of Patients: The Battle between Medical and Chiropractic Professional Associations over the Inclusion of Chiropractic in the American Medicare System

Health care professions struggling for legitimacy, recognition, and market share can become disoriented to their priorities. Health care practitioners are expected to put the interests of patients first. Professional associations represent the interests of their members. So when a professional association is composed of health care practitioners, its interests may differ from those of patients, creating a conflict for members. In addition, sometimes practitioners' perspectives may be altered by indoctrination in a belief system, or misinformation, so that a practitioner could be confused about the reality of patient needs. Politicians, in attempting to find an expedient compromise, can value a "win" in the legislative arena over the effects of that legislation. These forces all figure into the events that led to the acceptance of chiropractic into the American Medicare system. Two health care systems in a political fight lost sight of their main purpose: to provide care to patients without doing harm.

The immediate and 1-week effects of mid-thoracic thrust manipulation on lower extremity passive range of motion

BACKGROUND

Research suggests that spinal manipulation may effect motion. Less clear is whether this effect is limited to localized responses or may involve generalizable changes. Objective: To determine whether Mid-thoracic manipulation (MTM) would result in a significant change in the lower extremity passive straight leg raise (PSLR) range of motion immediately and after 1 week. Methods: Twenty-three healthy subjects were randomly assigned in a double-blinded study. An experimental group received MTM and a control group received a sham intervention. PSLR measurements were taken prior to, immediately after, and one week after the intervention. Results: Mixed model repeated measure analysis of variance was used to determine that there was a significant interaction between MTM and time (F(2, 21) = 3.84, p < 0.05). Post hoc tests revealed a significant difference between the pretest to immediate posttest values (p < 0.05, SE = 1.47). PSLR in the MTM group increased 10.3° while the sham group increased 1.9°. Difference was non-significant between pretest and 1-week follow-up (p = 0.129, SE = 2.46). Conclusions: MTM may immediately increase lower extremity passive range of motion, but the effect was lost by the 1-week follow-up. This supports evolving research suggesting that spinal manipulation may have a generalized but transient physiological effect.

The schism in chiropractic through the eyes of a 1st year chiropractic student

Since its inception, the chiropractic profession has been divided along ideological fault lines. These divisions have led to a profession wide schism, which has limited mainstream acceptance, utilisation, social authority and integration. The authors explore the historical origins of this schism, taking time to consider historical context, religiosity, perpetuating factors, logical fallacies and siege mentality. Evidence is then provided for a way forward, based on the positioning of chiropractors as mainstream partners in health care.

The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided

Background

Previous research has investigated utilization rates, who sees chiropractors, for what reasons, and the type of care that chiropractors provide. However, these studies have not been comprehensively synthesized. We aimed to give a global overview by summarizing the current literature on the utilization of chiropractic services, reasons for seeking care, patient profiles, and assessment and treatment provided.

Methods

Systematic searches were conducted in MEDLINE, CINAHL, and Index to Chiropractic Literature using keywords and subject headings (MeSH or ChiroSH terms) from database inception to January 2016. Eligible studies: 1) were published in English or French; 2) were case series, descriptive, cross-sectional, or cohort studies; 3) described patients receiving chiropractic services; and 4) reported on the following theme(s): utilization rates of chiropractic services; reasons for attending chiropractic care; profiles of chiropractic patients; or, types of chiropractic services provided. Paired reviewers independently screened all citations and data were extracted from eligible studies. We provided descriptive numerical analysis, e.g. identifying the median rate and interquartile range (e.g., chiropractic utilization rate) stratified by study population or condition.

Results

The literature search retrieved 14,149 articles; 328 studies (reported in 337 articles) were relevant and reported on chiropractic utilization (245 studies), reason for attending chiropractic care (85 studies), patient demographics (130 studies), and assessment and treatment provided (34 studies). Globally, the median 12-month utilization of chiropractic services was 9.1% (interquartile range (IQR): 6.7%-13.1%) and remained stable between 1980 and 2015. Most patients consulting chiropractors were female (57.0%, IQR: 53.2%-60.0%) with a median age of 43.4 years (IQR: 39.6-48.0), and were employed (median: 77.3%, IQR: 70.3%-85.0%). The most common reported reasons for people attending chiropractic care were (median) low back pain (49.7%, IQR: 43.0%-60.2%), neck pain (22.5%, IQR: 16.3%-24.5%), and extremity problems (10.0%, IQR: 4.3%-22.0%). The most common treatment provided by chiropractors included (median) spinal manipulation (79.3%, IQR: 55.4%-91.3%), soft-tissue therapy (35.1%, IQR: 16.5%-52.0%), and formal patient education (31.3%, IQR: 22.6%-65.0%).

Conclusions

This comprehensive overview on the world-wide state of the chiropractic profession documented trends in the literature over the last four decades. The findings support the diverse nature of chiropractic practice, although common trends emerged.

Spinal Manipulative Therapy and Sports Performance Enhancement: A Systematic Review

OBJECTIVE

The purpose of this study was to review the literature regarding the relationship between spinal manipulative therapy (SMT) and sports performance.

METHODS

PubMed and Embase databases were searched for original studies published up to July 2016. Inclusion criteria were if SMT has been applied to athletes and if any sports performance-related outcome was measured.

RESULTS

Of the 581 potential studies, 7 clinical trials were selected. Most studies had adequate quality (≥6/11) when assessed by the PEDro scale. None of those studies assessed performance at an event or competition. Four studies revealed improvement in a sports performance test after SMT. Meta-analysis could not be performed because of the wide differences in methodologies, design, and outcomes measured. Spinal manipulative therapy influences a wide range of neurophysiological parameters that could be associated with sports performance. Of the 3 studies where SMT did not improve test performance, 2 used SMT not for therapeutic correction of a dysfunctional vertebral joint but to an arbitrary previously set joint.

CONCLUSIONS

Although 4 of 7 studies showed that SMT improved sports performance tests, the evidence is still weak to support its use. Spinal manipulative therapy may be a promising approach for performance enhancement that should be investigated with more consistent methodologic designs.

Changes in the use practitioner-based complementary and alternative medicine over time in Canada: Cohort and period effects

BACKGROUND

The use of complementary and alternative medicine (CAM) is growing. However the factors contributing to changes over time and to birth cohort differences in CAM use are not well understood.

SETTING

We used data from 10186 participants, who were aged 20-69 years at the first cycle of data collection in the longitudinal component of the Canadian National Population Health Survey (1994/95-2010/11). We examined chiropractic and other practitioner-based CAM use with a focus on five birth cohorts: pre-World War II (born 1925-1934); World War II (born 1935-1944); older baby boomers (born 1945-1954); younger baby boomers (born 1955-1964); and Gen Xers (born 1965-1974). The survey collected data every two years on predisposing (e.g., sex, education), enabling (e.g., income), behavior-related factors (e.g., obesity), need (e.g., chronic conditions), and use of conventional care (primary care and specialists).

RESULTS

The findings suggest that, at corresponding ages, more recent cohorts reported greater CAM (OR = 25.9, 95% CI: 20.0; 33.6 for Gen Xers vs. pre-World War) and chiropractic use than their predecessors (OR = 2.2, 95% CI: 1.7; 2.8 for Gen Xers vs. pre-World War). There was also a secular trend of increasing CAM use, but not chiropractic use, over time (period effect) across all ages. Factors associated with cohort differences were different for CAM and chiropractic use. Cohort differences in CAM use were partially related to a period effect of increasing CAM use over time across all ages while cohort differences in chiropractic use were related to the higher prevalence of chronic conditions among recent cohorts. The use of conventional care was positively related to greater CAM use (OR = 1.8, 95% CI: 1.6; 2.0) and chiropractic use (OR = 1.2, 95% CI: 1.1; 1.4) but did not contribute to changes over time or to cohort differences in CAM and chiropractic use.

CONCLUSION

The higher CAM use over time and in recent cohorts could reflect how recent generations are approaching their healthcare needs by expanding conventional care to include CAM therapies and practice for treatment and health promotion. The findings also underscore the importance of doctors discussing CAM use with their patients.

Characteristics of US Adults Who Have Positive and Negative Perceptions of Doctors of Chiropractic and Chiropractic Care

OBJECTIVE

The purpose of this study was to compare characteristics, likelihood to use, and actual use of chiropractic care for US survey respondents with positive and negative perceptions of doctors of chiropractic (DCs) and chiropractic care.

METHODS

From a 2015 nationally representative survey of 5422 adults (response rate, 29%), we used respondents' answers to identify those with positive and negative perceptions of DCs or chiropractic care. We used the χ(2) test to compare other survey responses for these groups.

RESULTS

Positive perceptions of DCs were more common than those for chiropractic care, whereas negative perceptions of chiropractic care were more common than those for DCs. Respondents with negative perceptions of DCs or chiropractic care were less likely to know whether chiropractic care was covered by their insurance, more likely to want to see a medical doctor first if they were experiencing neck or back pain, less likely to indicate that they would see a DC for neck or back pain, and less likely to have ever seen a DC as a patient, particularly in the recent past. Positive perceptions of chiropractic care and negative perceptions of DCs appear to have greater influence on DC utilization rates than their converses.

CONCLUSION

We found that US adults generally perceive DCs in a positive manner but that a relatively high proportion has negative perceptions of chiropractic care, particularly the costs and number of visits required by such care. Characteristics of respondents with positive and negative perceptions were similar, but those with positive perceptions were more likely to plan to use-and to have already received-chiropractic care.

Identification of determinants of the utilisation of acupuncture treatment using Andersen's behavioural model

OBJECTIVES

The utilisation of healthcare services is the result of a complex decision-making process with different determinants. This study aims to identify the determinants of the utilisation of acupuncture treatment using Andersen's behavioural model and quality of life.

METHODS

In this study we reviewed Korean Health Panel data, a nationally representative set of data, and analysed the utilisation of outpatient acupuncture services during 2011. A two-part model, which included predisposing, enabling and need factors of Andersen's behavioural model in model 1 and the additional factor of health-related quality of life (HRQOL, EQ-5D Korean index) in model 2, was analysed by logistic analysis to identify determinants of acupuncture service usage among subjects who visited traditional Korean medical clinics.

RESULTS

The higher frequency of acupuncture service usage among patients who visited traditional Korean medical clinics was associated with gender, age, number of chronic diseases, physical disabilities and HRQOL of the subjects.

CONCLUSIONS

This study shows that the important determinants of the frequency of acupuncture treatment utilisation are gender, age, number of chronic diseases and the presence of physical disabilities. Our findings contribute to understanding the characteristics of patients who use acupuncture treatment and may be used as a basic resource for related policy making by government officials and medical professionals.

In vitro biomechanical evaluation of single impulse and repetitive mechanical shockwave devices utilized for spinal manipulative therapy

Mechanical shockwave therapy devices have been in clinical use for almost 40 years. While most often used to treat back pain, our understanding of their biomechanical performance is very limited. From biomechanical studies we know that biological tissue is viscoelastic and preferably excited around its resonance frequency. Targeting these frequencies has been the focus in extracorporeal shock wave lithotripsy, but these concepts are relatively new in orthopedic and rehabilitation therapies. The exact mechanism by which shockwave therapy acts is not known. Knowledge of the performance characteristics of these devices, correlated with clinical outcome studies, may lead to better patient selection, improvement of device functionality, and knowledge of the underlying working principals of therapy. The objectives of this study were to determine the ability of several commercial shockwave devices to achieve a desired thrust profile in a benchtop setting, determine the thrust profile in a clinical analog, and determine the influence of operator experience level on device performance. We conducted two different types of testing: (1) bench testing to evaluate the devices themselves, and (2) clinical equivalent testing to determine the influence of the operator. The results indicated a significant dependence of thrust output on the compliance of the test media. The Activator V-E device matched the ideal half-sine thrust profile to 94%, followed by the Impulse device (84%), the Activator IV/FS (74%), and the Activator II (48%). While most devices deviated from the ideal profile on the return path, the Impulse device exhibited a secondary peak. Moreover, the Activator V-E device provided evidence that the device performs consistently despite operator experience level. This has been a major concern in manual spinal manipulation. Based on our results, a hyper-flexible spine would receive a lower peak thrust force than a hypo-flexible spine at the same power setting. Furthermore, a hand-held operation further reduced the peak thrust force as it increased the system compliance. However, that influence was dissimilar for the different devices. Although controlled clinical trials are needed to determine the correlation between thrust profile and clinical outcome, already ongoing clinical studies indicate an improved patient satisfaction due to reduced treatment pain when devices are used with a thrust characteristic closer to an ideal sine wave.

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report

BACKGROUND

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report.

METHODS

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

RESULTS

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

CONCLUSIONS

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

Complementary and alternative medicine use in African Americans with rheumatoid arthritis

OBJECTIVE

Racial/ethnic differences with regard to complementary and alternative medicine (CAM) use have been reported in the US. However, specific details of CAM use by African Americans with rheumatoid arthritis (RA) are lacking.

METHODS

Data were collected from African Americans with RA enrolled in a multicenter registry regarding the use of CAM, including food supplements, topical applications, activities, and alternative care providers. Factors associated with CAM use by sex and disease duration were assessed using t-test, Wilcoxon's rank sum test, chi-square test, and logistic regression analyses.

RESULTS

Of the 855 participants, 85% were women and mean age at enrollment was 54 years. Overall, ever using any of the CAM treatments, activities, and providers was 95%, 98%, and 51%, respectively (median of 3 for number of treatments, median of 5 for activities, and median of 1 for providers). Those with longer disease duration (>2 years) were significantly more likely (odds ratio ≥2.0, P < 0.05) to use raisins soaked in vodka/gin, to take fish oils, or to drink alcoholic beverages for RA treatment than those with early disease. As compared to men, women were significantly (P < 0.05) more likely to pray/attend church, write in a journal, and use biofeedback, but were less likely to smoke tobacco or topically apply household oils for treatment of RA.

CONCLUSION

CAM use was highly prevalent in this cohort, even in individuals with early disease. Health care providers need to be aware of CAM use as some treatments may potentially have interactions with conventional medicines. This could be important within this cohort of African Americans, where racial disparities are known to affect access to conventional care.

Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B

BACKGROUND CONTEXT

Concern about improper payments to chiropractic physicians prompted the US Department of Health and Human Services to describe chiropractic services as a "significant vulnerability" for Medicare, but little is known about trends in the use and cost of chiropractic spinal manipulation provided under Medicare.

PURPOSE

To quantify the volume and cost of chiropractic spinal manipulation services for older adults under Medicare Part B and identify longitudinal trends.

STUDY DESIGN/SETTING

Serial cross-sectional design for retrospective analysis of administrative data.

PATIENT SAMPLE

Annualized nationally representative samples of 5.0 to 5.4 million beneficiaries.

OUTCOME MEASURES

Chiropractic users, allowed services, allowed charges, and payments.

METHODS

Descriptive statistics were generated by analysis of Medicare administrative data on chiropractic spinal manipulation provided in the United States from 2002 to 2008. A 20% nationally representative sample of allowed Medicare Part B fee-for-service claims was merged, based on beneficiary identifier, with patient demographic data. The data sample was restricted to adults aged 65 to 99 years, and duplicate claims were excluded. Annualized estimates of outcome measures were extrapolated, per beneficiary and per user rates were estimated, and volumes were stratified by current procedural terminology code.

RESULTS

The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.

CONCLUSIONS

Chiropractic claims account for less than 1/10th of 1% of overall Medicare expenditures. Allowed services, allowed charges, and fee-for-service payments for chiropractic spinal manipulation under Medicare Part B generally increased from 2002, peaked in 2005 and 2006, and then declined through 2008. Per user spending for chiropractic spinal manipulation also declined by 18% from 2006 to 2008, in contrast to 10% growth in total spending per beneficiary and 16% growth in overall Medicare spending.

Medicare's demonstration of expanded coverage for chiropractic services: limitations of the demonstration and an alternative direct cost estimate

OBJECTIVE

The purposes of this study were to examine the direct costs associated with Medicare's 2005-2007 "Demonstration of Expanded Coverage of Chiropractic Services" (Demonstration) and their drivers, to explore practice pattern variation during the Demonstration, and to describe scenarios of cost implications had provider behavior and benefit coverage been different.

METHODS

Using Medicare Part B data from April 1, 2005, and March 31, 2007, and 2004 Rural Urban Continuum Codes, we conducted a retrospective analysis of traditionally reimbursed and expanded chiropractic services provided to patients aged 65 to 99 years who had a neuromusculoskeletal condition. We compared chiropractic care costs, supply, and utilization patterns for the 2-year periods before, during, and after the Demonstration for 5 Chicago area counties that participated in the Demonstration to those for 6 other county aggregations-urban or rural counties that participated in the Demonstration; were designated comparison counties during the Demonstration; or were neither participating nor comparison counties during the Demonstration.

RESULTS

When compared with other groups, doctors of chiropractic in 1 region (Chicago area counties) billed more aggressively for expanded services and were reimbursed significantly more for traditionally reimbursed chiropractic services provided before, during, and after the Demonstration. Costs would have been substantially lower had doctors of chiropractic in this 1 region had responded similarly to those in other demonstration counties.

CONCLUSION

We found widespread geographic variation in practice behavior and patterns. Our findings suggest that Medicare might reduce the risk of accelerated costs associated with the introduction of a new benefit by applying appropriate limits to the frequency of use and overall costs of those benefits, particularly in highly competitive markets.

Use of traditional Korean medicine by patients with musculoskeletal disorders

BACKGROUND

South Korea has maintained a dual healthcare delivery system that incorporates both traditional Korean and Western medicine. In this research, we identified the determinants of the frequency of using traditional Korean medicine among musculoskeletal patients, who are known to be the most frequent users of complementary and alternative medicine.

METHODS

In this research, we reviewed 2 consecutive years of nationally representative survey data from the 2008 and 2009 Korea Health Panel Survey. We analyzed the utilization of outpatient services by musculoskeletal patients within 12 months of the 2009 survey date. A two-part model was used because some patients did not use traditional Korean medicine and skewness was present in the data on traditional Korean medicine use. In the first part, logistic regression analysis was performed to investigate the use of traditional Korean medicine. In the second part, multiple regression analysis was performed to analyze the frequency of traditional Korean medicine usage among the subjects who visited traditional Korean medical institutions.

RESULTS

The frequency of traditional Korean medicine usage was positively associated with ages of 40-49 years and over 60, restrictions on daily life, a greater number of chronic diseases, not being hospitalized, and more frequent visits (more than five times) to conventional hospitals or clinics for musculoskeletal disorders.

CONCLUSIONS

The important determinants of the frequency of traditional Korean medicine usage were age, activity restrictions, the number of chronic diseases, hospitalization history, and the number of visits to conventional hospitals for musculoskeletal disorders. The results contribute to our understanding of the characteristics of traditional Korean medicine users and may be used as a basic resource for related policymaking by government officials and medical professionals.

Racial disparities in the use of chiropractic care under Medicare

CONTEXT

Medicare covers chiropractic care, but the health-care community knows little about the demographic characteristics of older adults who use chiropractic services under the Medicare program. Researchers do not know the demographic composition of chiropractic users under Medicare, how the demographics of chiropractic use and rates of use have changed over time, and how users' characteristics vary geographically across the United States. An understanding of the demographics of chiropractic users can help chiropractic organizations, policy makers, and other stakeholders plan for an equitable allocation of resources to meet the chiropractic health-care needs of all of Medicare's beneficiaries.

OBJECTIVE

The study intended to evaluate Medicare administrative data to determine (1) longitudinal trends in the demographic composition of the population that used chiropractic services, (2) longitudinal trends in rates of chiropractic use by demographic group, and (3) geographic variations in chiropractic use among minorities.

DESIGN

The research team used a serial cross-sectional design to analyze administrative data for beneficiaries of Medicare during the years 2002 to 2008, using a 20% random sample that provided those beneficiaries' racial and geographical characteristics. The team restricted the study's actual sample to adults aged 65 to 99 and defined chiropractic users as beneficiaries who had at least one paid claim for chiropractic care on a date of service in an analyzed calendar year.

OUTCOME MEASURE(S)

For each state in the United States and the District of Columbia for each of the 7 years studied, the team determined the number of chiropractic users in total and the number of users in selected demographic categories and calculated percentage estimates and averages for each category. The team analyzed 2008 data for rates of use within racial groups and for geographic variations in those rates and quantified variations in rates by state using the coeffcient of variation (CV). The team mapped race-specific rates for selected minorities, categorized by quintiles, to illustrate geographic variations by state.

RESULTS

Analysis by beneficiary's race showed that the proportion of chiropractic users who were white hovered at 96% to 97% throughout the time period studied, while 1% to 2% were black. Each of the other racial categories comprised 1% or less of users, and the percentages showed little change over time. Rates among racial minorities showed greater geographic variation than did rates for whites. The greatest geographic variations in use by specific racial minorities occurred among Hispanics, Asians, and Native Americans.

CONCLUSION

The research team's results showed little longitudinal variation in the demographics of chiropractic use under Medicare but a striking difference in rates of use between whites and minorities, and substantial geographic variations in user rates among racial minorities. The research team's findings suggest the possibility that barriers may exist for minorities' access to chiropractic care. As minority populations in the United States continue to grow, the health-care community can expect that any impact on population health that these barriers cause will grow as well.

Use of chiropractic spinal manipulation in older adults is strongly correlated with supply

STUDY DESIGN

Retrospective cross-sectional analysis of administrative data.

OBJECTIVE

To examine the relationship between regional chiropractic supply and both use and utilization intensity of chiropractic services among Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

Numerous studies have documented trends and patterns in the utilization of chiropractic services in the United States, but little is known about geographic variation in the relationship between chiropractic supply and utilization.

METHODS

We analyzed Medicare claims data for services provided by chiropractic physicians in 2008. We aggregated the data to the hospital referral region level and used small area analysis techniques to generate descriptive statistics. We mapped geographic variations in chiropractic supply, use and utilization intensity (treatments per user), and quantified the variation by coefficient of variation and extremal ratio. We used Spearman rank correlation coefficient to correlate use with supply. We used a logistic regression model for chiropractic use and a multiple linear regression model for chiropractic utilization intensity.

RESULTS

The average regional supply of chiropractic physicians was 21.5 per 100,000 adult capita. The average percentage of beneficiaries who used chiropractic was approximately 7.6 (SD, 3.9). The average utilization intensity was 10.6 (SD, 1.8). Regional chiropractic supply varied more than 14-fold, and chiropractic use varied more than 17-fold. Chiropractic supply and use were positively correlated (Spearman ρ, 0.68; P < 0.001). A low back or cervical spine problem was strongly associated with chiropractic use (odds ratios, 21.6 and 14.3, respectively). Increased chiropractic supply was associated with increased chiropractic use (odds ratio, 1.04) but not with increased chiropractic utilization intensity.

CONCLUSION

Both the supply of chiropractors and the utilization of chiropractic by older US adults varied widely by region. Increased chiropractic supply was associated with increased chiropractic use but not with increased chiropractic utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference.

Chiropractic use, health care expenditures, and health outcomes for rural and nonrural individuals with arthritis

OBJECTIVE

Arthritis is considered the leading cause of disability among adults in the United States today and contributes substantially to the rising cost of health care. Residents of rural areas are especially affected. The purposes of this article are to describe chiropractic use by rural and nonrural individuals with arthritis and to identify differences in other health care use and health status by those using chiropractic care plus conventional care or conventional care alone.

METHODS

A longitudinal cohort from panel 12 (N = 12440) of the Medical Expenditure Panel Survey spanning 2007 to 2008 was selected for this study to represent changes in health care expenditures and use and outcomes throughout this period. The population was stratified by self-reported physician-diagnosed arthritis and rural status and compared across demographics, health status, and health care use and expenditures, including use of chiropractic services plus conventional care or conventional care alone.

RESULTS

Twice as many rural people with arthritis had 1 or more visits with a doctor of chiropractic compared with nonrural persons with arthritis. More rural chiropractic users with arthritis reported their perceived health status as excellent, very good, or good compared with nonrural chiropractic users with arthritis and to rural people with arthritis who reported no chiropractic visits. Health care expenditures for other physician services were higher among rural chiropractic users with arthritis than nonrural users with arthritis.

CONCLUSIONS

Differences in chiropractic use were observed between rural and nonrural individuals with arthritis. More studies are needed to investigate these differences and the impact on health care use and expenditures and outcomes of individuals with arthritis.

The Ecology of Medical Care in Norway: Wide Use of General Practitioners may not Necessarily Keep Patients out of Hospitals

BACKGROUND

Our aim was to investigate the pattern of self reported symptoms and utilisation of health care services in Norway.

DESIGN AND METHODS

With data from the cross-sectional Tromsø Study (2007-8), we estimated population proportions reporting symptoms and use of seven different health services. By logistic regression we estimated differences according to age and gender.

RESULTS

In this study 12,982 persons aged 30-87 years participated, constituting 65.7% of those invited. More than 900/1000 reported symptoms or health problems in a year as well as in a month, and 214/1000 and 816/1000 visited a general practitioner once or more in a month and a year, respectively. The corresponding figures were 91/1000 and 421/1000 for specialist outpatient visits, and 14/1000 and 116/1000 for hospitalisations. Physiotherapists were visited by 210/1000, chiropractors by 76/1000, complementary and alternative medical providers by 127/1000, and dentists by 692/1000 in a year. Women used most health care services more than men, but genders used hospitalisations and chiropractors equally. Utilisation of all services increased with age, except chiropractors, dentists and complementary and alternative medical providers.

CONCLUSIONS

Almost the entire population reported health related problems during the previous year, and most residents visited a general practitioner. Yet there were high rates of inpatient and outpatient specialist utilisation. We suggest that wide use of general practitioners may not necessarily keep patients out of specialist care and hospitals.

ACKNOWLEDGMENTS

the authors would like to thank Tor Anvik for a significant contribution in developing the idea for the study, Tom Wilsgård for useful discussions about the statistical analyses and Jarl-Stian Olsen for graphic design of the figures. They would also thank the people of Tromsø and The Tromsø Study for giving data to this study. Northern Norway Regional Health Authority and The University of Tromsø funded this research.

Epidemiology: spinal manipulation utilization

The objectives of this article are to (1) describe spinal manipulation use by time, place, and person, and (2) identify predictors of the use of spinal manipulation. We conducted a systematic review of the English-language literature published from January 1, 1980 through June 30, 2011. Of 822 citations identified, 213 were deemed potentially relevant; 75 were included after further consideration. Twenty-one additional articles were identified from reference lists. The literature is heavily weighted toward North America, Europe, and Australia and thus largely precludes inferences about spinal manipulation use in other parts of the world. In the regions covered by the literature, chiropractors, osteopaths, and physical therapists are most likely to deliver spinal manipulation, often in conjunction with other conservative therapies. Back and neck pain are the most frequent indications for receiving spinal manipulation; non-musculoskeletal conditions comprise a very small percentage of indications. Although spinal manipulation is more commonly used in adults than children, evidence suggests that spinal manipulation may be more likely used for non-musculoskeletal ailments in children than in adults. Patient satisfaction with spinal manipulation is very high.

Effect of cervical spine manipulative therapy on judo athletes' grip strength

OBJECTIVE

The objective of this study was to perform an investigation evaluating if cervical spinal manipulative therapy (SMT) can increase grip strength on judo athletes in a top 10 national-ranked team.

METHODS

A single-blinded, prospective, comparative, pilot, randomized, clinical trial was performed with 18 athletes of both sexes from a judo team currently competing on a national level. The athletes were randomly assigned to 2 groups: chiropractic SMT and sham. Three interventions were performed on each of the athletes at different time points. Force measurements were obtained by a hydraulic dynamometer immediately before and after each intervention at the same period before training up to 3 weeks with at least 36 hours between interventions.

RESULTS

Analysis of grip strength data revealed a statistically significant increase in strength within the treatment group after the first intervention (6.95% right, 12.61% left) as compared with the second (11.53% right, 17.02% left) and the third interventions (10.53% right, 16.81% left). No statistically significant differences were found in grip strength comparison within the sham group. Overall differences in strength were consistently significant between the study groups (P = .0025).

CONCLUSION

The present study suggests that the grip strength of national level judo athletes receiving chiropractic SMT improved compared to those receiving sham.

Implications and limitations of appropriateness studies for chiropractic

OBJECTIVE

The appropriate role for chiropractic in US health care has not been established, but third-party payors and public policy makers must make decisions about the appropriate role for chiropractors in health care systems and for the services that chiropractors provide. Appropriateness studies for chiropractic may inform those decisions. The purpose of this article is to discuss the implications and limitations of appropriateness studies for chiropractic.

DISCUSSION

We reviewed the general context for assessment of the appropriateness and the application of appropriateness studies to chiropractic in particular. We evaluated the implications and limitations for chiropractic of methods of small area analysis and the RAND-UCLA Appropriateness Method. The RAND-UCLA Appropriateness Method has been applied to the evaluation of spinal manipulation. Regional variations in chiropractic utilization have yet to be described through small area analysis, but these methods appear to hold some potential for assessing the appropriateness of chiropractic care. Both small area analysis and the RAND-UCLA method offer limited possibilities for the assessment of chiropractic appropriateness.

CONCLUSION

Future assessment of the appropriate role for chiropractic in US health care will raise issues beyond the scope of previous appropriateness studies. Studying the appropriate role for chiropractic will require consideration of the clinical discipline in its entirety, rather than individual consideration of specific interventions. A fair assessment of chiropractic appropriateness will require new evidence and perhaps new research methodologies.

The attrition rate of licensed chiropractors in California: an exploratory ecological investigation of time-trend data

Background

The authors hypothesized the attrition rate of licensed chiropractors in California has gradually increased over the past several decades. "Attrition" as determined for this study is defined as a loss of legal authority to practice chiropractic for any reason during the first 10 years after the license was issued. The percentage of license attrition after 10 years was determined for each group of graduates licensed in California each year between 1970 and 1998. The cost of tuition, the increase in the supply of licensed chiropractors and the ratio of licensed chiropractors to California residents were examined as possible influences on the rate of license attrition.

Methods

The attrition rate was determined by a retrospective analysis of license status data obtained from the California Department of Consumer Affairs. Other variables were determined from US Bureau of Census data, survey data from the American Chiropractic Association and catalogs from a US chiropractic college.

Results

The 10-year attrition rate rose from 10% for those graduates licensed in 1970 to a peak of 27.8% in 1991. The 10-year attrition rate has since remained between 20-25% for the doctors licensed between 1992-1998.

Conclusions

Available evidence supports the hypothesis that the attrition rate for licensed chiropractors in the first 10 years of practice has risen in the past several decades.

Manipulative therapy for pregnancy and related conditions: a systematic review

OBJECTIVE

The objective of this review is to evaluate the evidence on the effects of Spinal Manipulative Therapy (SMT) on back pain and other related symptoms during pregnancy.

DATA SOURCES

A literature search was conducted using Pubmed, Manual, Alternative and Natural Therapy Index System, Cumulated Index to Nursing and Allied Health, Index to Chiropractic Literature, the Cochrane Library, and Google Scholar. In addition hand searches and reference tracking were also performed, and the citation list was assessed for comprehensiveness by content experts.

METHODS OF STUDY SELECTION

This review was limited to peer-reviewed manuscripts published in English from 1966 until September 2008. The initial search strategy yielded 140 citations of which 12 studies were reviewed for quality.

TABULATION, INTEGRATION, AND RESULTS

The methodological quality of the included studies was assessed independently using quality checklists of the Scottish Intercollegiate Guidelines Network and Council on Chiropractic Guidelines and Practice Parameters. The review indicates that the use of SMT during pregnancy to reduce back pain and other related symptoms is supported by limited evidence.

CONCLUSION

Overall, this body of evidence is best described as emergent. However, since effective treatments for pregnancy-related back pain are limited, clinicians may want to consider SMT as a treatment option, if no contraindications are present.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the concepts of spinal manipulative therapy and types of symptoms for which it might be considered in pregnancy, explain the quality of available research on the use of spinal manipulative therapy, and plan to discuss this therapy with interested pregnant patients.

Complementary and alternative medicine use among primary care patients in west Texas

BACKGROUND

This study explored factors related to practitioner-based complementary and alternative medicine (CAM) usage among primary care clinic patients in rural West Texas areas, including physicians' awareness of their patients' CAM use.

METHODS

A convenience sample was drawn from nine clinics that served low-income populations. Surveys were distributed to patients during a 6-week period in the winter of 2006. The analytical sample included 1731 participants. Logistic regressions were conducted to explore the factors related to CAM use.

RESULTS

Of 1731 subjects, 52.0% (900) reported that they were currently using or had used CAM. The main types of CAM practitioners were chiropractor (42.7%) followed by massage therapist (33.3%) and herbalist (8.3%). Those who had discussed the use of alternative medicine with their physicians and those who had more days where they felt worried in the past 30 days were more likely to use CAM than their counterparts. Patients whose healthcare was covered by nonprivate insurance, those who rated their healthcare providers more highly, and those who agreed that their doctor visits were obtainable were less likely to use CAM.

CONCLUSIONS

CAM use is clearly not uncommon among primary care patients in rural areas, with more than half of patients reporting some type of use. This study suggests that further research should elicit opinions on CAM among people who do not regularly access a conventional primary care provider, as well as assess the relationship between CAM and conventional medical treatment in terms of cost and health benefits.

Chiropractic utilization in Taekwondo athletes

The purpose of the present study was to examine chiropractic utilization following a sport-related injury among National Team members and other high level Taekwondo athletes.

METHODS

Retrospective surveys were conducted among Canadian male and female Taekwondo athletes (Group A, n = 60) competing in a national tournament and National Taekwondo team athletes (Group B, n = 16) at a training camp.

RESULTS

A response rate of 46.7% (Group A) and 100% (Group B) was achieved. Twenty five percent (n = 4) of Group A athletes reported never seen a doctor of chiropractic (DC) regarding their injuries. Over 12% (n = 2) reported visiting a DC often, while just over 6% (n = 1) reported that they usually visited the DC following an injury. When injured, over 36% (n = 7) of the National Team members visit their family physician, over 15% (n = 3) visit a chiropractor or physiotherapist and the remaining athletes (n = 6) equally visit osteopaths, massage therapists, or athletic therapist following an injury.

CONCLUSION

There is a lack of information surrounding chiropractic utilization in the majority of sports and minimal research published regarding the health care utilization of Taekwondo athletes. Chiropractors, and particularly those with extensive athlete contact, should endeavour to further utilization studies.

The use of chiropractors by older adults in the United States

Background

In a nationally representative sample of United States Medicare beneficiaries, we examined the extent of chiropractic use, factors associated with seeing a chiropractor, and predictors of the volume of chiropractic use among those having seen one.

Methods

We performed secondary analyses of baseline interview data on 4,310 self-respondents who were 70 years old or older when they first participated in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). The interview data were then linked to their Medicare claims. Multiple logistic and negative binomial regressions were used.

Results

The average annual rate of chiropractic use was 4.6%. During the four-year period (two years before and two years after each respondent's baseline interview), 10.3% had one or more visits to a chiropractor. African Americans and Hispanics, as well as those with multiple depressive symptoms and those who lived in counties with lower than average supplies of chiropractors were much less likely to use them. The use of chiropractors was much more likely among those who drank alcohol, had arthritis, reported pain, and were able to drive. Chiropractic services did not substitute for physician visits. Among those who had seen a chiropractor, the volume of chiropractic visits was lower for those who lived alone, had lower incomes, and poorer cognitive abilities, while it was greater for the overweight and those with lower body limitations.

Conclusion

Chiropractic use among older adults is less prevalent than has been consistently reported for the United States as a whole, and is most common among Whites, those reporting pain, and those with geographic, financial, and transportation access.