A health care system in transformation: making the case for chiropractic

Interprofessional Attitudes and Interdisciplinary Practices for Older Adults With Back Pain Among Doctors of Chiropractic: A Descriptive Survey

OBJECTIVE

The purpose of this study is to report on attitudes of doctors of chiropractic (DCs) toward integrative medicine and their self-reported interdisciplinary practices for older adults with back pain.

METHODS

This descriptive survey was conducted with licensed DCs in a Midwestern community in the United States. Respondents completed a 53-item postal survey of demographics, practice characteristics, referral and co-management patterns, attitudes toward interdisciplinary practice, and the Integrative Medicine-30 Questionnaire (IM-30). Descriptive statistical analysis was performed.

RESULTS

Fifty-seven DCs completed the survey (29% response). Geriatric-focused chiropractic practices were uncommon (<15%), although 56% reported that 25% to 49% of the patients treated each week were older adults. Respondents had a moderate orientation toward collaboration with other health care providers (IM-30 mean [standard deviation] 61.3 [11.5]). The IM-30 subscales placed DCs high on measures of integrative medicine safety; moderate on patient-centeredness, openness to working with other providers, and referral readiness; and low on learning from alternative paradigms. Doctors of chiropractic most referred older patients to neurologists, family physicians, massage therapists, orthopedists, and other chiropractors. Doctors of chiropractic reported the highest levels of co-management with family physicians, physical therapists, and massage therapists. Most DCs (92%) were confident in their own ability to manage back pain in older adults, with modest confidence expressed for treatments from professionals using manual therapies. Most (77%) responded that older patients would experience the most improvement if DCs collaborated with another chiropractor, rather than with medical professionals.

CONCLUSION

Doctors of chiropractic in one geographic community are moderately oriented toward interprofessional practice with other health care providers for older adults with back pain. Follow-up studies in representative national and international samples are recommended.

Use of Integrative Medicine in the United States Military Health System

Integrative medicine (IM) is a model of care which uses both conventional and nonconventional therapies in a "whole person" approach to achieve optimum mental, physical, emotional, spiritual, and environmental health, and is increasingly popular among patients and providers seeking to relieve chronic or multifactorial conditions. The US Department of Defense (DoD) shows particular interest in and usage of IM for managing chronic conditions including the signature "polytrauma triad" of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD) among its beneficiaries in the Military Health System (MHS). These modalities range from conventional nondrug, nonsurgical options such as cognitive-behavioral therapy to nonconventional options such as acupuncture, chiropractic, and mind-body techniques. These are of particular interest for their potential to relieve symptoms without relying on opiates, which impair performance and show high potential for abuse while often failing to provide full relief. This review describes the use of IM in the MHS, including definitions of the model, common therapies and potential for use, and controversy surrounding the practice. More research is needed to build a comprehensive usage analysis, which in turn will inform sound clinical and financial practice for the MHS and its beneficiaries.

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.

Similarities and differences of a selection of key accreditation standards between chiropractic councils on education: a systematic review

BACKGROUND

Councils of Chiropractic Education (CCE) indirectly influence patient care and safety through their role of ensuring the standards of training delivered by chiropractic educational institutions. This is achieved by a process of accreditation where CCEs define and assess graduate competencies and educational standards. A previous study comparing CCE graduate competencies found variations between the CCE jurisdictions. It was proffered that variations in standards may potentially compromise patient care and safety and also inter-jurisdictional mutual recognition. This study continues the examination of CCEs by looking for similarities and differences in CCE accreditation standards. There were two purposes of this review. The first was to compare the accreditation standards, domains of accreditation standards, and components of the domains of accreditation standards as represented by the domains of "Mission, goals, vision, objectives", "Resources", "Faculty/Academic staff", "Educational program/curriculum". In addition, we compared the accreditation standards between CCEs and those of the widely accepted medical accreditation standards of the World Federation of Medical Education (WFME), in order to search for deficiencies and opportunities for improvements in these standards. The second purpose was to make recommendations, if significant deficiencies or variations were found.

METHOD

We undertook a systematic review of the similarities and differences between five CCEs' definitions of an accreditation standard and the descriptive lists of accreditation standards they have adopted. CCE selection criteria and data selection method were undertaken in a systematic manner. This information was tabulated for a comparative analysis and took place in April 2016.

RESULTS

Only two CCEs had a definition of the term "accreditation / educational standard". At the domain level there was considerably more similarities than differences. The differences became more apparent when the comparisons were made at the component level. These included intended purposes of the mission statement, standards for faculty staff, requirements for clinical training by students, program budgetary autonomy and transparency, the inclusion of chiropractic philosophy and history, and which subjects should be taught in basic, behavioural and clinical sciences.

CONCLUSIONS

A series of recommendations were made. These included the need for an increased clarity of the required basic and clinical science subjects, teaching clinic student requirements, and faculty staff qualifications. These are proposed with the intention of creating uniform and high quality international accreditation standards for chiropractic education. Future research should compare the levels of CCEs inspection standards and processes to see if similarities and differences exist also there.

TRIAL REGISTRATION

Not applicable.

Health care encounters in Danish chiropractic practice from a consumer perspectives - a mixed methods investigation

Background

Perceived value is the key ingredient to carving and maintaining a competitive business niche. The opportunities to interact with consumers to understand and enhance perceived value are termed ‘touch points’. Due to the out-of-pocket expense incurred by patients, Danish chiropractors are subject to consumer trends and behaviors. The purpose of this investigation was to explore and describe consumer touch points relevant to perceived value through healthcare journeys in chiropractic practices.

Method

We designed a convergent parallel, mixed methods study. Our purposive sampling framework identified 11 chiropractic clinics from which we collected observational field notes, video recordings and face-to-face interviews.

Results

Data was collected between April 14^th and June 26^th 2014. We described the exteriors and interiors of all participant clinics, interviewed 32 staff members, 12 new patients and 36 follow-up patients and finally video recorded 11 new and 24 follow-up consultations. Categorization and analysis led to the emergence six consumer touch point themes: ‘the internet’, ‘the physical environment’, ‘practice models’, ‘administrative staff’, ‘the consultation sequence and timing’ and ‘a consultation that adds value’. The Internet functions as a tool when choosing/confirming a clinic as appropriate, developing and initial image and managing appointments. The administrative hub appears integral to the shaping of positive consumer experiences outside of the consultation. Clinic location, practice model and interior design may contribute to context effects and thus may influence value perception during the clinical encounter. The duration of hands-on treatment received from the chiropractor is not an apparent consumer focus point. Rather, through a seven stage clinical procedure patients value consultations with clinicians who demonstrate professional competence by effective communication diagnosis/management and facilitating satisfactory treatment outcomes.

Conclusion

At least six consumer touch points add/detract from value-related experiences in chiropractic practices. The duration of hands-on treatment per se does not appear to be a particular focus point. More research is required to explore this issue.

How can we assess the burden of muscle, bone and joint conditions in rural Botswana: context and methods for the MuBoJo focused ethnography

BACKGROUND

Musculoskeletal diseases are the most common causes of long-term pain and disability worldwide and a growing international public health concern. However, the everyday burden and impact of musculoskeletal conditions are not well understood, especially among people living in low- and middle-income countries in Africa. Since 2011, World Spine Care, a nongovernmental organisation, has collaborated with the Botswana Ministry of Health to open spine care centres and to conduct research. The broad aim of the Muscle, Bone and Joint (MuBoJo) research project is to examine the sociocultural, organisational and clinical characteristics for the burden of living with and caring for people living with musculoskeletal conditions in rural Botswana. In this paper, we describe the community context, theoretical framework, and research methods to address the project aim with a qualitative study.

METHODS/DESIGN

This focused ethnography is based on eight months (November 2011, April 2013, October 2013-March 2014) of fieldwork in Botswana. The project was theoretically informed by the concepts of explanatory models of illness, social suffering, and biographical disruption. Data collection included fieldnotes, non-participant and participant observations, and informal and in-depth interviews with villagers and healthcare providers. Villager interviews were typically conducted in Setswana with an interpreter. Audio recordings were transcribed verbatim in the language spoken with Setswana contextually translated into English. Computer software supported qualitative data management. Analysis is ongoing using constant comparison and a template organising style to facilitate pattern-finding and reveal insights for the burden and care of musculoskeletal conditions.

DISCUSSION

Findings from the MuBoJo Project will document the context of musculoskeletal burden, illness beliefs, self-care behaviours, and healthcare options in a Botswana rural village. These data will inform ongoing efforts to establish spine care clinics for underserved populations in low-middle income countries and sustain these healthcare services through local providers and volunteer health professionals. This study also will generate new knowledge about the burden and impact of muscle, bone and joint disorders for cross-cultural comparisons and patient-centred interventions.

CONCLUSIONS

Our systematic and transparent methodology to conduct musculoskeletal research in more than one language and in a cross-cultural setting may be useful for investigators and NGO healthcare personnel.

A survey of Australian chiropractors' attitudes and beliefs about evidence-based practice and their use of research literature and clinical practice guidelines

Background

Research into chiropractors’ use of evidence in clinical practice appears limited to a single small qualitative study. The paucity of research in this area suggests that it is timely to undertake a more extensive study to build a more detailed understanding of the factors that influence chiropractors’ adoption of evidence-based practice (EBP) principles. This study aimed to identify Australian chiropractors’ attitudes and beliefs towards EBP in clinical practice, and also examine their use of research literature and clinical practice guidelines.

Methods

We used an online questionnaire about attitudes, beliefs and behaviours towards the use of EBP in clinical practice that had been developed to survey physiotherapists and modified it to ensure that it was relevant to chiropractic practice. We endeavoured to survey all registered Australian chiropractors (n = 4378) via email invitation distributed by Australian chiropractic professional organisations and the Chiropractic Board of Australia. Logistic regression analyses were conducted to examine univariate associations between responses to items measuring attitudes and beliefs with items measuring: age; years since registration; attention to literature; and use of clinical practice guidelines.

Results

Questionnaires were returned by 584 respondents (response rate approximately 13%). The respondents’ perceptions of EBP were generally positive: most agreed that the application of EBP is necessary (77.9%), literature and research findings are useful (80.2%), EBP helps them make decisions about patient care (66.5%), and expressed an interest in learning or improving EBP skills (74.9%). Almost half of the respondents (45.1%) read between two to five articles a month. Close to half of the respondents (44.7%) used literature in the process of clinical decision making two to five times each month. About half of the respondents (52.4%) agreed that they used clinical practice guidelines, and around half (54.4%) agreed that they were able to incorporate patient preferences with clinical practice guidelines. The most common factor associated with increased research uptake was the perception that EBP helps make decisions about patient care.

Conclusions

Most Australian chiropractors hold positive attitudes towards EBP, thought EBP was useful, and were interested in improving EBP skills. However, despite the favourable inclination towards EBP, many Australian chiropractors did not use clinical practice guidelines. Our findings should be interpreted cautiously due to the low response rate.

On Vaccination & Chiropractic: when ideology, history, perception, politics and jurisprudence collide

The Palmers espoused anti-vaccination opinions in the early part of the 20(th) century, rejecting the germ theory of disease in favor of a worldview that a subluxation-free spine, achieved by spinal adjustments, would result in an unfettered innate intelligence; this, along with other healthful lifestyle choices, would allow a person to thwart disease by marshaling the body's natural recuperative abilities. Some chiropractors continue to staunchly champion the Palmer postulates, while others do not. At the national level, advocacy organizations publish conflicting position statements. We explore how this divisiveness has impacted chiropractic ideology, perceptions among students and practitioners, politics and issues of jurisprudence as reflected by the evolution of a standard of chiropractic practice in at least one Canadian province (Ontario). We opine that the chiropractic profession should champion a health promotion and disease prevention approach to vaccination, which would allow it to align itself with the broader healthcare community while not abandoning its traditional tenets.