The establishment of a primary spine care practitioner and its benefits to health care reform in the United States

Healthcare provider perspectives on integrating a comprehensive spine care model in an academic health system: a cross-sectional survey

BACKGROUND

Healthcare systems (HCS) are challenged in adopting and sustaining comprehensive approaches to spine care that require coordination and collaboration among multiple service units. The integration of clinicians who provide first line, evidence-based, non-pharmacological therapies further complicates adoption of these care pathways. This cross-sectional study explored clinician perceptions about the integration of guideline-concordant care and optimal spine care workforce requirements within an academic HCS.

METHODS

Spine care clinicians from Duke University Health System (DUHS) completed a 26-item online survey via Qualtrics on barriers and facilitators to delivering guideline concordant care for low back pain patients. Data analysis included descriptive statistics and qualitative content analysis.

RESULTS

A total of 27 clinicians (57% response) responded to one or more items on the questionnaire, with 23 completing the majority of questions. Respondents reported that guidelines were implementable within DUHS, but no spine care guideline was used consistently across provider types. Guideline access and integration with electronic records were barriers to use. Respondents (81%) agreed most patients would benefit from non-pharmacological therapies such as physical therapy or chiropractic before receiving specialty referrals. Providers perceived spine patients expected diagnostic imaging (81%) and medication (70%) over non-pharmacological therapies. Providers agreed that receiving imaging (63%) and opioids (59%) benchmarks could be helpful but might not change their ordering practice, even if nudged by best practice advisories. Participants felt that an optimal spine care workforce would require more chiropractors and primary care providers and fewer neurosurgeons and orthopedists. In qualitative responses, respondents emphasized the following barriers to guideline-concordant care implementation: patient expectations, provider confidence with referral pathways, timely access, and the appropriate role of spine surgery.

CONCLUSIONS

Spine care clinicians had positive support for current tenets of guideline-concordant spine care for low back pain patients. However, significant barriers to implementation were identified, including mixed opinions about integration of non-pharmacological therapies, referral pathways, and best practices for imaging and opioid use.

Using medical storytelling to communicate problems and solutions in the low back pain conundrum: an evidence-based tale of twins

OBJECTIVES

Low back pain (LBP) is the number one cause of disability world-wide. It is also the most expensive area in healthcare. Patient-centered innovations are needed. This paper uses medical storytelling to illustrate the common problems that often lead to unnecessary suffering for patients, and costs to society. We present innovative solutions, including narrative interventions.

METHODS

We use medical storytelling to present a scenario in which hypothetical twin patients with identical LBP episodes enter the healthcare system, with one twin managed in an appropriate manner, and the other inappropriately.

RESULTS

One twin becomes a chronic LBP sufferer, while the other experiences quick resolution, despite identical conditions. Recommendations are made to de-implement inappropriate action and to implement a more productive approach.

CONCLUSIONS

Many patients with LBP descend into chronic pain. This is rarely inevitable based on clinical factors. Much of chronic LBP results from how the condition is handled within the healthcare system. Medical narrative may be one innovation to illustrate the problem of current LBP management, recommend solutions and foster changes in clinical behavior.

PRACTICAL IMPLICATIONS

The starkly different outcomes for each identical twin are illustrated. Recommendations are made for reframing the situation to de-implement the inappropriate and to implement a more appropriate approach.

The Inclusion of Chiropractic Care in the Healthy China Initiative 2030

The Healthy China Initiative 2030 represents a major shift in China's healthcare policies for health promotion and disease prevention. Chiropractic care, with its focus on musculoskeletal health and nonpharmacological treatment, can contribute to the goals of this initiative. However, its potential contribution is hampered by the lack of official recognition and regulation in mainland China, which restricts its general awareness and integration into healthcare systems, and potentially leads to untreated musculoskeletal disorders. This research proposes the inclusion of chiropractic care in the Healthy China Initiative 2030 framework. It provides an overview of the goals of this initiative and the current state of chiropractic care in China. The alignment of chiropractic principles and practices with the aims of the Healthy China Initiative 2030 is also discussed. Policy recommendations for integrating chiropractic care into the healthcare system are proposed, which include the establishment of education standards, licensing protocols, and collaborative research initiatives. Potential challenges, including regulatory barriers, a lack of awareness, and research limitations are highlighted. We also present potential strategies to leverage opportunities for promoting chiropractic care, such as the rising demand for musculoskeletal care. This research provides the first focused discussion on the integration of chiropractic care into China's evolving preventive healthcare landscape under the Healthy China Initiative 2030.

Effectiveness of spinal manipulation and biopsychosocial self-management compared to medical care for low back pain: a randomized trial study protocol

BACKGROUND

Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis.

METHODS

We have designed a phase 3 randomized trial with a 2 × 2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment.

DISCUSSION

By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03581123.

Effectiveness of Spinal Manipulation and Biopsychosocial Self-Management compared to Medical Care for Low Back Pain: A Randomized Trial Study Protocol

Background Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis. Methods We have designed a phase 3 randomized trial with a 2x2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment. Discussion By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem. Trial registration: ClinicalTrials.gov Identifier: NCT03581123.

Chiropractors in interprofessional practice settings: a narrative review exploring context, outcomes, barriers and facilitators

To determine the added value of interprofessional interventions over existing mono-professional practice, elucidation of specific health care issues, service delivery contexts and benefits of combining multiple service provider is required. However, from existing literature, it is difficult to develop a sense of the evidence that supports interprofessional practice initiatives involving chiropractors. This review aims to describe and explore the contexts, outcomes, and barriers and facilitators relating to interprofessional practice involving chiropractors available in current literature. A search of Scopus, CINAHL, Cochrane, and Web of Science databases covering the literature from 2005 to October 2021 was conducted, after which a narrative review of identified peer-reviewed articles written in English was performed. We included data from seven studies, conducted across four distinct service delivery contexts. Eight interprofessional practice partners were identified, and eight factors appear to act as barriers and facilitators. Data suggests that incorporating chiropractors into community health and sports medicine interprofessional practice interventions is achievable and appears to impact collaborative practice positively. For older adults with low back pain, quality of life and care-related satisfaction are potential relevant outcomes for the evaluation of interprofessional practice interventions. There is currently very limited evidence from which to judge the value of interprofessional practice interventions, as available literature appears to focus mainly on interprofessional collaboration. Studies conducted specifically to evaluate interprofessional practice solutions and addressing specific health care issues or practice domains are urgently required.

Online access to spine care: do institutions advertise themselves as multidisciplinary?

Background

The primary aim of our study is to assess the extent to which healthcare systems advertise their spine care programs as multidisciplinary and furthermore clarify whether these institutions accurately reflect this description in their online access to spine care. The secondary aim of our study is to determine what proportion of institutions enable patients to self-schedule appointments online and select providers.

Methods

Newsweek's 2021 list entitled "Best Hospitals 2021-United States" was utilized to obtain an extensive list of top-rated hospitals in the country. Institutions were considered to be advertising themselves as multidisciplinary if they used this term or similar wording (such as "care encompassing broad range of specialties", "interdisciplinary", "multidisciplinary"). Each institution's website was additionally assessed for the existence of: (I) a standard overview website or multiple individual sites for respective spine-focused divisions (i.e., orthopaedic surgery, neurosurgery, physical medicine and rehabilitation, anesthesiology); (II) online self-scheduling; (III) triage questions prior to requesting appointments; and (IV) selection choice for specific providers.

Results

In total, 334 institutions were included in analysis, with 66% utilizing multidisciplinary terminology in describing their institution on their website. However, most institutions only had a standard overview website with no separate websites for respective divisions (54%). Institutions described as multidisciplinary were more likely to have a link on a central page to each division (31% vs. 4%, P<0.001). No significant differences were found between institutions described as multidisciplinary and those not described as such when considering triage questions, online self-scheduling, and choice of provider.

Conclusions

Though the majority of spine care centers are described as multidisciplinary, the patient experience when navigating websites online does not always meet this standard. Further progress in website design, automated triaging, and online scheduling are needed to truly achieve multidisciplinary care.

The primary spine practitioner as a new role in healthcare systems in North America

Background

In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies.

Main body

The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly.

Conclusion

Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.

Efficiency of primary spine care as compared to conventional primary care: a retrospective observational study at an Academic Medical Center

BACKGROUND

Primary Spine Care (PSC) is an innovative model for the primary management of patients with spine-related disorders (SRDs), with a focus on the use of non-pharmacological therapies which now constitute the recommended first-line approach to back pain. PSC clinicians serve as the initial or early point of contact for spine patients and utilize evidence-based spine care pathways to improve outcomes and reduce escalation of care (EoC; e.g., spinal injections, diagnostic imaging, hospitalizations, referrals to a specialist). The present study examined 6-month outcomes to evaluate the efficiency of care for patients who received PSC as compared to conventional primary care. We hypothesized that patients seen by a PSC clinician would have lower rates of EoC compared to patients who received usual care by a primary care (PC) clinician.

METHODS

This was a retrospective observational study. We evaluated 6-month outcomes for two groups seen and treated for an SRD between February 01, 2017 and January 31, 2020. Patient groups were comprised of N = 1363 PSC patients (Group A) and N = 1329 PC patients (Group B). We conducted Pearson chi-square and logistic regression (adjusting for patient characteristics that were unbalanced between the two groups) to determine associations between the two groups and 6-month outcomes.

RESULTS

Within six months of an initial visit for an SRD, a statistically significantly smaller proportion of PSC patients utilized healthcare resources for spine care as compared to the PC patients. When adjusting for patient characteristics, those who received care from the PSC clinician were less likely within 6 months of an initial visit to be hospitalized (OR = .47, 95% CI .23-.97), fill a prescription for an opioid analgesic (OR = .43; 95% CI .29-.65), receive a spinal injection (OR = .56, 95% CI .33-.95), or have a visit with a specialist (OR = .48, 95% CI .35-.67) as compared to those who received usual primary care.

CONCLUSIONS

Patients who received PSC in an academic primary care clinic experienced significantly less escalation of their spine care within 6 months of their initial visit. The PSC model may offer a more efficient approach to the primary care of spine problems for patients with SRDs, as compared to usual primary care.

Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain

Together, neck pain and back pain are the first cause of disability worldwide, accounting for more than 10% of the total years lived with disability. In this context, chiropractic care provides a safe and effective option for the management of a large proportion of these patients. Chiropractic is a healthcare profession mainly focused on the spine and the treatment of spinal disorders, including spine pain. Basic studies have examined the influence of chiropractic spinal manipulation (SM) on a variety of peripheral, spinal and supraspinal mechanisms involved in spine pain. While spinal cord mechanisms of pain inhibition contribute at least partly to the pain-relieving effects of chiropractic treatments, the evidence is weaker regarding peripheral and supraspinal mechanisms, which are important components of acute and chronic pain. This narrative review highlights the most relevant mechanisms of pain relief by SM and provides a perspective for future research on SM and spine pain, including the validation of placebo interventions that control for placebo effects and other non-specific effects that may be induced by SM. SIGNIFICANCE: Spinal manipulation inhibits back and neck pain partly through spinal segmental mechanisms and potentially through peripheral mechanisms regulating inflammatory responses. Other mechanisms remain to be clarified. Controls and placebo interventions need to be improved in order to clarify the contribution of specific and non-specific effects to pain relief by spinal manipulative therapy.

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

IMPORTANCE

Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.

OBJECTIVE

To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.

DESIGN, SETTING, AND PARTICIPANTS

This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.

EXPOSURES

SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).

MAIN OUTCOMES AND MEASURES

Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.

RESULTS

Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

The Manchurian candidate: chiropractors as propagators of neoliberalism in health care

The rise of neoliberalism has influenced the health care sector, including the chiropractic profession. The neoliberal infiltration of market justice behavior is in direct conflict with the fiduciary agreement to serve the public good before self-interests and has compromised the chiropractor, who now may act as an agent of neoliberalism in health care. The purpose of this paper is to present an overview of the impact of neoliberalism on the chiropractic profession and provide recommendations for a professional philosophical shift from a market justice model to a communal and social justice model.

Anatomical Sciences in Chiropractic Education: A Survey of Chiropractic Programs in Australia

Human anatomy knowledge is a core requirement for all health care clinicians. There is a paucity of information relating to anatomy content and delivery in Australian chiropractic programs. The aim of this study was to describe anatomy teaching in Australian chiropractic programs, utilizing a survey which was distributed to all four programs, requesting information on: anatomy program structure, delivery methods, assessment, teaching resources, and academic staff profile at their institution. The survey was undertaken in 2016 and documented practices in that academic year. All four institutions responded. There was a reported difference in the teaching hours, content, delivery and assessment of anatomy utilized in Australian chiropractic programs. Anatomy was compulsory at all four institutions with the mean total of 214 (SD ± 100.2) teaching hours. Teaching was undertaken by permanent ongoing (30%) and sessional academic staff, and student to teacher ratio varied from 15:1 to 12:1. A variety of teaching resources were utilized, including human tissue access, either as prosected cadavers or plastinated body parts. The results of this survey confirm that anatomy has an established place in chiropractic education programs in Australia and while curricular variations exist, all programs had similar course design, delivery, and assessment methods. This study confirmed the provision of a strong foundation in topographical anatomy and neuroanatomy, while other anatomical sciences, such as histology and embryology were not consistently delivered. Formalization of a core anatomy curriculum together with competency standards is needed to assist program evaluation and development, and for accreditation purposes.

If I was more informed about what exactly they do: perceptions of Botswana district hospital healthcare providers about World Spine Care

Background

In 2011, World Spine Care (WSC) opened their pilot clinic at the Botswana Mahalapye District Hospital (MDH) aiming to develop a low-cost model of evidence-based spine care for underserved communities. Providing sustainable, integrated, evidence-based care will require buy-in from local healthcare providers (HCPs) and the communities served. The purpose of this project was to understand how MDH HCPs perceive WSC.

Methods

We used a qualitative descriptive methodology to conduct individual, semi-structured interviews with MDH HCPs who had some familiarity about WSC services. Interviews were conducted in English, audio-recorded, and transcribed verbatim. We used an iterative coding process for thematic content analysis and interpretations were regularly reviewed by all co-authors.

Results

In March 2017, interviews with 20 HCPs, from diverse disciplines with a range in years’ experience at MDH, revealed three overlapping themes: knowledge about WSC and spinal related disorders, perceived role of WSC, and challenges for WSC integration. Participants who attended WSC conferences or self-referred for care were more informed and, generally, held positive perceptions. Participants lacked knowledge about managing spinal-related disorders, asserted hospital protocols did not meet patient needs, and perceived WSC is ‘filling a gap’ to manage these conditions. There were mixed perceptions about care received as WSC patients; some ultimately obtained relief, while others reported the treatment painful and unfamiliar, discharging themselves from care. Challenges to integrate WSC into the healthcare system were: lack of knowledge about scope of practice and unclear referral pathways; reversing the isolated care WSC provides by increasing collaboration between WSC and hospital staff; and, high turnover of WSC clinicians that undermines program sustainability.

Conclusions

MDH healthcare providers had adequate general knowledge about World Spine Care and spinal-related disorders, but did not understand the WSC scope of practice nor referral pathways to and from providers. Participants advocated for greater collaboration between WSC and hospital staff to increase acceptance and integration to deliver spine care services and foster wider adoption of the WSC model, particularly if WSC expands services across Botswana. Future efforts that incorporate interviews with patients and government officials also can provide valuable perspectives to achieve sustainable, integrated, evidence-based spine care.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0250-2) contains supplementary material, which is available to authorized users.

Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team

Background

While chiropractors are integrating into multidisciplinary settings with increasing frequency, the perceptions of medical providers and patients toward adding chiropractors to existing healthcare teams is not well-understood. This study explored the qualities preferred in a chiropractor by key stakeholders in a neurorehabilitation setting.

Methods

This qualitative analysis was part of a multi-phase, organizational case study designed to evaluate the planned integration of a chiropractor into a multidisciplinary rehabilitation team. The setting was a 62-bed rehabilitation specialty hospital located in the northeastern United States. Participants included patients, families, community members, and professional staff of the administrative, medical, nursing, and therapy departments. Data collection consisted of audiotaped, individual interviews and profession-specific focus groups guided by a semi-structured interview schedule. Transcripts were imported into a qualitative data analysis program for data analysis. An iterative coding process using thematic content analysis categorized key themes and domains.

Results

Sixty participants were interviewed in June 2015, including 48 staff members, 6 patients, 4 family members, and 2 community members. Our analysis generated a conceptual model of The Preferred Chiropractor for Multidisciplinary Rehabilitation Settings composed of 5 domains and 13 themes. The central domain, Patient-Centeredness, or the provision of healthcare that is respectful, responsive, and inclusive of the patient’s values, preferences, and needs, was mentioned in all interviews and linked to all other themes. The Professional Qualities domain highlighted clinical acumen, efficacious treatment, and being a safe practitioner. Interpersonal Qualities encouraged chiropractors to offer patients their comforting patience, familiar connections, and emotional intelligence. Interprofessional Qualities emphasized teamwork, resourcefulness, and openness to feedback as characteristics to enhance the chiropractor’s ability to work within an interdisciplinary setting. Organizational Qualities, including personality fit, institutional compliance, and mission alignment were important attributes for working in a specific healthcare organization.

Conclusions

Our findings provide an expanded view of the qualities that chiropractors might bring to multidisciplinary healthcare settings. Rather than labeling stakeholder perceptions as good, bad or indifferent as in previous studies, these results highlight specific attributes chiropractors might cultivate to enhance the patient outcomes and the experience of healthcare, influence clinical decision-making and interprofessional teamwork, and impact healthcare organizations.

Electronic supplementary material

The online version of this article (10.1186/s12998-018-0200-4) contains supplementary material, which is available to authorized users.

Chiropractic Management of a Patient With Chronic Pain in a Federally Qualified Health Center: A Case Report

Objective

The aim of this case report is to describe the response of a patient with chronic pain who received chiropractic care in a federally qualified health center.

Clinical Features

A 61-year-old female patient with neck and back pain after a traumatic motor vehicle accident 3 years prior was referred for chiropractic care. She had neck pain, low back pain, knee pain, and pain associated with over 20 surgeries, as well as depression, opioid dependence, and low quality of life.

Interventions and Outcomes

The patient was treated with chiropractic manipulation for her low back and neck pain and was counseled on nutrition and exercise. After 6 months, she reported improvements in pain, improved quality of life, and discontinuation of opioid pain medication.

Conclusion

This patient improved after a course of chiropractic care that was integrated into a federally qualified health center.

A treatise for a new philosophy of chiropractic medicine

BACKGROUND

The philosophy of chiropractic has been a much debated entity throughout the existence of the chiropractic profession. Much criticism has been passed upon the historical philosophy of chiropractic and propagated by contemporary adherents. To date, a new philosophy has not been detailed nor presented that demonstrates principles by which to follow.

AIM

The purpose of this paper is to expand upon the work of Russell Kirk (b.1918, d. 1994), an American political theorist, as a basis for principles to guide the formation of a philosophy of chiropractic medicine (PCM). Each of Kirk's principles will be explained and expounded upon as applicable to a PCM. The addition of the term "medicine" to chiropractic is indicative of a new direction for the profession.

DISCUSSION

The ten principles that provide a foundation for a PCM include: (a) moral order, (b) custom, convention and continuity, (c) prescription, (d) prudence, (e) variety, (f) imperfectability, (g) freedom and property linkage, (h) voluntary community and involuntary collectivism, (i) prudent restraints upon power and human passions, and (j) permanence and change. Each of these principles offers not a dogmatic approach but provides insight into the application of chiropractic medicine to the entire station of the patient and society at large especially that of the economic, social and political. These principles provide direction in not only the approach to the doctor-patient encounter but can be used to visualize the wider world and its potential impact. Instead, these principles examine many tangential issues worthy of discussion that may impact health, social, political, and economic policy and how the chiropractic profession can approach these issues.

CONCLUSION

This paper provides the initial steps in formulating a PCM using principles from a sociological, political and economic standpoint which may impact on how chiropractic medicine approaches the patient and society in totality. In addition, these principles provide the necessary first steps in the arena of the social, political and economic aspects and how chiropractic medicine can advance.

'PICO-D Management'; a decision-aid for evidence-based chiropractic education and clinical practice

Background

Various models and decision-making aids exist for chiropractic clinical practice.

Results

“PICO-D Man” (Patient-Intervention-Comparator-Outcome-Duration Management) is a decision-aid developed in an educational setting which field practitioners may also find useful for applying defensible evidence-based practice. Clinical decision-making involves understanding and evaluating both the proposed clinicalintervention(s) and the relevant and available management options with respect to describing the patient and their problem, clinical and cost effectiveness, safety, feasibility and time-frame.

Conclusions

For people consulting chiropractors this decision-aid usually requires the practitioner to consider a comparison of usual chiropractic care, (clinical management including a combination of active care and passive manual interventions), to usual medical care usually including medications, or other allied healthmanagement options while being mindful of the natural history of the persons’ condition.

Professional Identity at Los Angeles College of Chiropractic

OBJECTIVE

The objective of this article is to describe chiropractic professional identity as espoused by the Los Angeles College of Chiropractic.

DISCUSSION

Professional identity is a construct that begins formation prior to career selection, can be considered the backbone of health care education, and has been linked to career success. Los Angeles College of Chiropractic's professional identity is shaped by a philosophy of health care that is focused on vitalism, holism, naturalism, therapeutic conservatism, critical rationalism, phenomenology, humanism, and interprofessionalism. Other distinguishing aspects include portal-of-entry professionals with broad diagnostic skills; a focus on spine care; promotion of public-health; and delivery of manual treatments.

CONCLUSION

The chiropractic professional identity at the Los Angeles College of Chiropractic focuses on serving the needs of the people who entrust their health to its graduates and will continue to evolve on the basis of many factors, such as politics, social perceptions, and economic conditions.

The Swiss Master in Chiropractic Medicine Curriculum: Preparing Graduates to Work Together With Medicine to Improve Patient Care

OBJECTIVE

In 2007, chiropractic became 1 of the 5 medical professions in Switzerland. This required a new chiropractic program that was fully integrated within a Swiss medical school. The purpose of this article was to discuss the Master in Chiropractic Medicine (MChiroMed) program at the University of Zürich, including advantages, opportunities, and challenges.

DISCUSSION

In 2008, the MChiroMed program began with its first student cohort. The MChiroMed program is a 6-year Bologna model 2-cycle (bachelor and master) "spiral curriculum," with the first 4 years being fully integrated within the medical curriculum. A review of the main features of the curriculum revealed the advantages, opportunities, and challenges of this program in comparison with other contemporary chiropractic educational programs. Advantages and opportunities include an integrated curriculum within a university, medical school, and musculoskeletal hospital, with their associated human and physical resources. Many opportunities exist for high-level research collaborations. The rigorous entrance qualifications and small student cohorts result in bright, motivated, and enthusiastic students; appropriate assessments; and timely feedback on academic and clinical subjects. Early patient contact in hospitals and clinical facilities encourages the integration of academic theory and clinical practice. The main challenges faced by this program include difficulty recruiting a sufficient number of students because of the rigorous entrance requirements and curriculum overload resulting from undertaking a full medical curriculum and chiropractic modules.

CONCLUSIONS

The MChiroMed program is a unique chiropractic curriculum that integrates medical and chiropractic education within a spiral curriculum at a world-class Swiss university medical school. The expectation is that graduates, with their expanded diagnostic and therapeutic knowledge, skills, and experience, will become future experts in primary spine care in Switzerland. It is hoped that this curriculum model will be adopted by other countries and jurisdictions seeking to enhance the role of chiropractic in health care.

Spine Care as a Framework for the Chiropractic Identity

OBJECTIVE

The purpose of this commentary is to provide an argument for the role and identity of chiropractors as spine care providers within the context of the greater health care system.

DISCUSSION

Surveys of the general public and chiropractors indicate that the majority of patients seek chiropractic services for back and neck pain. Insurance company utilization data confirm these findings. Regulatory and legal language found in chiropractic practice acts reveals that most jurisdictions define the chiropractic scope of practice as based on a foundation of spine care. Educational accrediting and testing organizations have been shaped around a chiropractic education that produces graduates who focus on the diagnosis and treatment of spine and musculoskeletal disorders. Spine care is thus the common denominator and theme throughout all aspects of chiropractic practice, legislation, and education globally.

CONCLUSION

Although the chiropractic profession may debate internally about its professional identity, the chiropractic identity seems to have already been established by society, practice, legislation, and education as a profession of health care providers whose area of expertise is spine care.

The effect of chiropractic treatment on the reaction and response times of special operation forces military personnel: study protocol for a randomized controlled trial

Background

Chiropractic care is commonly used to treat musculoskeletal conditions and has been endorsed by clinical practice guidelines as being evidence-based and cost-effective for the treatment of patients with low back pain. Gaps in the literature exist regarding the physiological outcomes of chiropractic treatment. Previous pilot work has indicated the possibility of improvements in response time following the application of chiropractic treatment. However, it is unknown whether or not chiropractic treatment is able to improve reaction and response times in specific populations of interest. One such population is the U.S. military special operation forces’ (SOF) personnel.

Methods

This study is a randomized controlled trial of 120 asymptomatic volunteer SOF personnel. All participants are examined by a study doctor of chiropractic (DC) for eligibility prior to randomization. The participants are randomly allocated to either a treatment group receiving four treatments of chiropractic manipulative therapy (CMT) over 2 weeks or to a wait-list control group. The wait-list group does not receive any treatment but has assessments at the same time interval as the treatment group. The outcome measures are simple reaction times for dominant hand and dominant foot, choice reaction time with prompts calling for either hand or either foot, response time using Fitts’ law tasks for small movements involving eye-hand coordination, and brief whole body movements using the t-wall, a commercially available product. At the first visit, all five tests are completed so that participants can familiarize themselves with the equipment and protocol. Assessments at the second and the final visits are used for data analysis.

Discussion

SOF personnel are highly motivated and extremely physically fit individuals whose occupation requires reaction times that are as quick as possible during the course of their assigned duties. A goal of CMT is to maximize the functionality and integration of the neuromusculoskeletal systems. Therefore, chiropractic treatment may be able to optimize the capacity of the numerous components of those systems, resulting in improved reaction time. The objective of this study is to test the hypothesis that CMT improves reaction and response times in asymptomatic SOF personnel.

Trial registration

ClinicalTrials.gov, NCT02168153. Registered on 12 June 2014.

A commentary on the implications of medication prescription rights for the chiropractic profession

There is a growing desire within the chiropractic profession to expand the scope of practice to include limited medication prescription rights for the treatment of spine-related and other musculoskeletal conditions. Such prescribing rights have been successfully incorporated into a number of chiropractic jurisdictions worldwide. If limited to a musculoskeletal scope, medication prescription rights have the potential to change the present role of chiropractors within the healthcare system by paving the way for practitioners to become comprehensive specialists in the conservative management of spine / musculoskeletal disorders. However, if the chiropractic profession wishes to lobby to expand the scope of practice to include limited prescriptive authority, several issues must first be addressed. These would include changes to chiropractic education and legislation, as well as consideration of how such privileges could impact the chiropractic profession on a more theoretical basis. In this commentary, we examine the arguments in favour of and against limited medication prescription rights for chiropractors and discuss the implications of such privileges for the profession.

Assessment of chiropractic treatment for active duty, U.S. military personnel with low back pain: study protocol for a randomized controlled trial

BACKGROUND

Low back pain is highly prevalent and one of the most common causes of disability in U.S. armed forces personnel. Currently, no single therapeutic method has been established as a gold standard treatment for this increasingly prevalent condition. One commonly used treatment, which has demonstrated consistent positive outcomes in terms of pain and function within a civilian population is spinal manipulative therapy provided by doctors of chiropractic. Chiropractic care, delivered within a multidisciplinary framework in military healthcare settings, has the potential to help improve clinical outcomes for military personnel with low back pain. However, its effectiveness in a military setting has not been well established. The primary objective of this study is to evaluate changes in pain and disability in active duty service members with low back pain who are allocated to receive usual medical care plus chiropractic care versus treatment with usual medical care alone.

METHODS/DESIGN

This pragmatic comparative effectiveness trial will enroll 750 active duty service members with low back pain at three military treatment facilities within the United States (250 from each site) who will be allocated to receive usual medical care plus chiropractic care or usual medical care alone for 6 weeks. Primary outcomes will include the numerical rating scale for pain intensity and the Roland-Morris Disability Questionnaire at week 6. Patient reported outcomes of pain, disability, bothersomeness, and back pain function will be collected at 2, 4, 6, and 12 weeks from allocation.

DISCUSSION

Because low back pain is one of the leading causes of disability among U.S. military personnel, it is important to find pragmatic and conservative treatments that will treat low back pain and preserve low back function so that military readiness is maintained. Thus, it is important to evaluate the effects of the addition of chiropractic care to usual medical care on low back pain and disability.

TRIAL REGISTRATION

The trial discussed in this article was registered in ClinicalTrials.gov with the NCT01692275 Date of registration: 6 September 2012.

Chiropractic identity, role and future: a survey of North American chiropractic students

Background

The literature pertaining to chiropractic students’ opinions with respect to the desired future status of the chiropractic physician is limited and is an appropriate topic worthy of study. A previous pilot study was performed at a single chiropractic college. This current study is an expansion of this pilot project to collect data from chiropractic students enrolled in colleges throughout North America.

Objective

The purpose of this study is to investigate North American chiropractic students’ opinions concerning professional identity, role and future.

Methods

A 23-item cross-sectional electronic questionnaire was developed. A total of 7,455 chiropractic students from 12 North American English-speaking chiropractic colleges were invited to complete the survey. Survey items encompassed demographics, evidence-based practice, chiropractic identity and setting, and scope of practice. Data were collected and descriptive statistical analysis was performed.

Results

A total of 1,247 (16.7% response rate) questionnaires were electronically submitted. Most respondents agreed (34.8%) or strongly agreed (52.2%) that it is important for chiropractors to be educated in evidence-based practice. A majority agreed (35.6%) or strongly agreed (25.8%) the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes. A large number of respondents (55.2%) were not in favor of expanding the scope of the chiropractic profession to include prescribing medications with appropriate advanced training. Most respondents estimated that chiropractors should be considered mainstream health care practitioners (69.1%). Several respondents (46.8%) think that chiropractic research should focus on the physiological mechanisms of chiropractic adjustments.

Conclusion

The chiropractic students in this study showed a preference for participating in mainstream health care, report an exposure to evidence-based practice, and desire to hold to traditional chiropractic theories and practices. The majority of students would like to see an emphasis on correction of vertebral subluxation, while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories. Further research on this topic is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-014-0048-1) contains supplementary material, which is available to authorized users.

Chiropractors as Primary Spine Care Providers: precedents and essential measures

Chiropractors have the potential to address a substantial portion of spinal disorders; however the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other health care professions such as podiatry/chiropody, physiotherapy and naturopathy have successfully gained public and professional trust, increases in scope of practice and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the health care system, the establishment of a 'primary spine care provider' may be a worthwhile niche position to create for society's needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders. Such changes have already been achieved by the chiropractic profession in Switzerland, Denmark, and New Mexico, whose examples may serve as important templates for renewal here in Canada.

The case for orthopaedic medicine in Israel

BACKGROUND

Musculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists.

METHODS

In order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel's large non-profit HMO's, and the domains of the visits to an orthopaedic surgeon.

RESULTS

Orthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO's. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training.

DISCUSSION

While orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the "Orthopaedic Medicine Lacuna" is responsible for inadequate treatment of non-surgical problems of the musculoskeletal system with immense financial implications. We present a preliminary probe into possible solutions which could be relevant to many developed countries.

Essential literature for the chiropractic profession: a survey of chiropractic research leaders

Background

Evidence-based clinical practice (EBCP) is an accepted practice for informed clinical decision making in mainstream health care professions. EBCP augments clinical experience and can have far reaching effects in education, policy, reimbursement and clinical management. The proliferation of published research can be overwhelming—finding a mechanism to identify literature that is essential for practitioners and students is desirable. The purpose of this study was to survey leaders in the chiropractic profession on their opinions of essential literature for doctors of chiropractic, faculty, and students to read or reference.

Methods

Deployment of an IRB exempted survey occurred with 68 academic and research leaders using SurveyMonkey®. Individuals were solicited via e-mail in August of 2011; the study closed in October of 2011.

Collected data were checked for citation accuracy and compiled to determine multiple responses. A secondary analysis assessed the scholarly impact and Internet accessibility of the recommended literature.

Results

Forty-three (43) individuals consented to participate; seventeen (17) contributed at least one article of importance. A total of 41 unique articles were reported. Of the six articles contributed more than once, one article was reported 6 times, and 5 were reported twice.

Conclusions

A manageable list of relevant literature was created. Shortcomings of methods were identified, and improvements for continued implementation are suggested. A wide variety of articles were reported as “essential” knowledge; annual or bi-annual surveys would be helpful for the profession.

The rationale for primary spine care employing biopsychosocial, stratified and diagnosis-based care-pathways at a chiropractic college public clinic: a literature review

Current management practices for low back pain have led to rising costs without evidence of improvement in the quality of care. Low back pain remains a diagnostic and management challenge for practitioners of many types and is now thought to be a leading global cause of disability. Beyond many published clinical practice guidelines, there are emerging, evidence-based care-pathways including stratification according to the patient's prognosis, classification-based management, diagnosis-based clinical decision guides and biopsychosocial models of care. A proposed solution for successfully addressing low back pain is to train residents at a chiropractic college public clinic to function as primary spine care practitioners, employing evidence-based care-pathways. The rationale for such is described with expected benefits to patient care, improved financial health of medical delivery systems and the training of chiropractors to successfully fill a niche in the healthcare system.