Chiropractic and Public Health: Current State and Future Vision

Chiropractic Day 2023: A Report and Qualitative Analysis of How Thought Leaders Celebrate the Present and Envision the Future of Chiropractic

Objective

This study aimed to (1) collect and analyze statements about how to celebrate chiropractic in the present and roles that chiropractors may fulfill in the future, (2) identify if there was congruence among the themes between present and future statements, and (3) offer a model about the chiropractic profession that captures its complex relationships that encompass its interactions within microsystem, mesosystem, exosystem, and macrosystem levels.

Methods

For this qualitative analysis, we used pattern and grounded theory approaches. A purposive sample of thought leaders in the chiropractic profession were invited to answer the following 2 open-ended questions: (1) envision the chiropractor of the future, and (2) recommendations on how to celebrate chiropractic. Information was collected during April 2023 using Survey Monkey. The information was entered into a spreadsheet and analyzed for topic clusters, which resulted in matching concepts with social-ecological themes. The themes between the responses to the 2 questions were analyzed for congruence. We used the Standards for Reporting Qualitative Research to report our findings.

Results

Of the 54 experts invited, 32 (59%) participated. Authors represented 7 countries and have a median of 32 years of chiropractic experience, with a range of 5 to 51 years. Nineteen major topics in the future statements and 23 major topics in statements about celebrating chiropractic were combined in a model. The topics were presented using the 4 levels of the social-ecological framework. Individual (microsystem): chiropractors are competent, well-educated experts in spine and musculoskeletal care who apply evidence-based practices, which is a combination of the best available evidence, clinical expertise, and patient values. Interpersonal relationships (mesosystem): chiropractors serve the best interests of their patients, provide person-centered care, embrace diversity, equity, and inclusion, consider specific health needs and the health of the whole person. Community (exosystem): chiropractors provide care within integrated health care environments and in private practices, serve the best interests of the public through participation in their communities, participate through multidisciplinary collaboration with and within the health care system, and work together as a profession with a strong professional identity. Societal (macrosystem): chiropractors contribute to the greater good of society and participate on a global level in policy, leadership, and research. There was concordance between both the future envisioning statements and the present celebration recommendations, which suggest logical validity based on the congruence of these concepts.

Conclusion

A sample of independent views, including the perceptions from a broad range of chiropractic thought leaders from various backgrounds, philosophies, diversity characteristics, and world regions, were assembled to create a comprehensive model of the chiropractic profession. The resulting model shows an array of intrinsic values and provides the roles that chiropractors may provide to serve patients and the public. This study offers insights into the roles that future chiropractors may fulfill and how these are congruent with present-day values. These core concepts and this novel model may have utility during dialogs about identity, applications regarding chiropractic in policy, practice, education, and research, and building positive relationships and collaborations.

Prevalence of Chiropractic-Specific Terminology on Chiropractors' Websites in the United Kingdom With Comparison to Australia: An Analysis of Samples

OBJECTIVE

The purpose of this study was to compare the prevalence of 5 chiropractic-specific terms on UK chiropractic websites to findings in a previous study in Australia and to provide an argument against the use of these terms.

METHODS

We searched websites belonging to chiropractors registered with the General Chiropractic Council for 5 terms: subluxation, vital(-ism/-istic), wellness, adjust(-ing/-ment), and Innate (Intelligence). Of 3239 websites, 326 were sampled. Each page was searched, and terms were counted only if used in a chiropractic-specific context. Term occurrence and frequency were recorded. The data were analyzed using a single-sample χ² goodness-of-fit test for unequal proportions. The results were compared to those of our prior Australian study, using the χ² test of homogeneity to determine the differences between samples.

RESULTS

At least 1 of the 5 chiropractic-specific terms was found on 245 (75%) of UK websites. Adjust(-ing/-ment) was found on 222 (68%) of UK websites compared to 283 (77%) in Australia; wellness on 67 (5%) of UK sites compared to 199 (33%) in Australia; vital(-ism/-istic) on 30 (9%) of UK sites compared to 71 (19%) in Australia; subluxation on 17 (5%) of UK sites compared to 104 (28%) in Australia; and Innate on 10 (3%) of UK sites compared to 39 (11%) in Australia. A χ² test found that the terms were not equally distributed in the two samples, χ 4 2  = 404.080, P < .001. In the discussion, we explain why we feel that chiropractic-specific terms should be abandoned and standard biomedical terms used.

CONCLUSION

In the sample of websites we evaluated in this study, the majority in the United Kingdom used the 5 chiropractic-specific terms that we searched for. The terms were used less frequently than on websites in Australia but were in a similar order of prevalence.

Income as a Predictor of Self-Efficacy for Managing Pain and for Coping With Symptoms Among Patients With Chronic Low Back Pain

OBJECTIVES

The purpose of this study was to evaluate pain self-efficacy (PSE) and coping self-efficacy (CSE) for people with chronic low back pain (CLBP), and to assess whether lower income may be associated with less PSE and CSE in the United States.

METHODS

We conducted a cross-sectional study using survey data collected between June 2016 and February 2017 from n = 1364 patients with CLBP from chiropractic clinics in the United States to measure the relationship between income and both types of self-efficacy. We created 4 multivariate models predicting PSE and CSE scores. We used both a parsimonious set of covariates (age, sex) and a full set (age, sex, education, neck pain comorbidity, catastrophizing, and insurance). We also calculated effect sizes (Cohen's d) for unadjusted differences in PSE and CSE score by income.

RESULTS

Lower income was associated with lower PSE and CSE scores across all 4 models. In the full models, the highest-income group had an average of 1 point (1-10 scale) higher PSE score and CSE score compared to the lowest income group. Effect sizes for the unadjusted differences in PSE and CSE scores between the highest and lowest income groups were 0.94 and 0.84, respectively.

CONCLUSIONS

Our findings indicate that people with lower income perceive themselves as less able to manage their pain, and that this relationship exists even after taking into account factors like health insurance and educational attainment. There is a need to further investigate how practitioners and policymakers can best support low-income patients with chronic pain.

Looking back at the lawsuit that transformed the chiropractic profession part 6: Preparing for the lawsuit

OBJECTIVE

This is the sixth article in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this article is to provide a brief review of the plaintiffs, lead lawyer, and the events immediately before the lawsuit was filed.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 articles following a successive timeline. This article, the sixth of the series, explores the plaintiffs' stories.

RESULTS

Because of the AMA's boycott on chiropractic, chiropractors were not able to collaborate with medical physicians or refer patients to medical facilities, which resulted in restricted trade and potential harm to patients' well-being. The plaintiffs, Patricia Arthur, James Bryden, Michael Pedigo, and Chester Wilk, came from different regions of the United States. Each had unique experiences and were compelled to seek justice. The lead lawyer, Mr George McAndrews, was the son of a chiropractor and had witnessed the effect that the AMA's attacks on chiropractic had on his father. It took several years to gather enough resources to file the suit, which was submitted in 1976.

CONCLUSION

The conflicts that the plaintiffs experienced stimulated them to pursue a lawsuit against the AMA and other organized political medicine groups.

Looking back at the lawsuit that transformed the chiropractic profession part 4: Committee on Quackery

OBJECTIVE

This is the fourth article in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit, in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this article is to provide a brief review of the history of the origins of AMA's increased efforts to contain and eliminate the chiropractic profession and the development of the Chiropractic Committee, which would later become the AMA Committee on Quackery.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 articles following a successive timeline. This article is the fourth of the series that explores the origins of AMA's increased efforts to contain and eliminate the chiropractic profession.

RESULTS

In the 1950s, the number of chiropractors grew in Iowa, and chiropractors were seeking equity with other health professions through legislation. In response, the Iowa State Medical Society created a Chiropractic Committee to contain chiropractic and prompted the creation of the "Iowa Plan" to contain and eliminate the chiropractic profession. The AMA leadership was enticed by the plan and hired the Iowa State Medical Society's legislative counsel, who structured the operation. The AMA adopted the Iowa Plan for nationwide implementation to eradicate chiropractic. The formation of the AMA's Committee on Chiropractic, which was later renamed the Committee on Quackery (CoQ), led overt and covert campaigns against chiropractic. Both national chiropractic associations were fully aware of many, but not all, of organized medicine's plans to restrain chiropractic.

CONCLUSION

By the 1960s, organized medicine heightened its efforts to contain and eliminate the chiropractic profession. The intensified campaign began in Iowa and was adopted by the AMA as a national campaign. Although the meetings of the AMA committees were not public, the war against chiropractic was distributed widely in lay publications, medical sources, and even chiropractic journals. Details about events would eventually be more fully revealed during the Wilk v AMA trials.

Looking back at the lawsuit that transformed the chiropractic profession part 2: Rise of the American Medical Association

OBJECTIVE

This paper is the second in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated anti-trust law by restraining chiropractors' business practices. The purpose of this paper is to provide a brief review of the history of how the AMA rose to dominate health care in the United States, and within this social context, how the chiropractic profession fought to survive in the first half of the 20th century.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive timeline. This paper is the second of the series that explores the growth of medicine and the chiropractic profession.

RESULTS

The AMA's code of ethics established in 1847 continued to direct organized medicine's actions to exclude other health professions. During the early 1900s, the AMA established itself as "regular medicine." They labeled other types of medicine and health care professions, such as chiropractic, as "irregulars" claiming that they were cultists and quacks. In addition to the rise in power of the AMA, a report written by Abraham Flexner helped to solidify the AMA's control over health care. Chiropractic as a profession was emerging and developing in practice, education, and science. The few resources available to chiropractors were used to defend their profession against attacks from organized medicine and to secure legislation to legalize the practice of chiropractic. After years of struggle, the last state in the US legalized chiropractic 79 years after the birth of the profession.

CONCLUSION

In the first part of the 20th century, the AMA was amassing power as chiropractic was just emerging as a profession. Events such as publication of Flexner's report and development of the medical basic science laws helped to entrench the AMA's monopoly on health care. The health care environment shaped how chiropractic grew as a profession. Chiropractic practice, education, and science were challenged by trying to develop outside of the medical establishment. These events added to the tensions between the professions that ultimately resulted in the Wilk v AMA lawsuit.

Looking back at the lawsuit that transformed the chiropractic profession part 1: Origins of the conflict

OBJECTIVE

This paper is the first in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to provide a brief review of the history of the AMA and the origins of chiropractic and to explore how the AMA began its monopoly of health care in the United States, possible reasons that organized medicine acted against chiropractic, and how these events influenced the chiropractic profession.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. We used primary and secondary data sources. The final narrative recount was developed into 8 papers that follow a successive time line. This paper is the first of the series and explores the origins of the aversion of organized American medicine to other health professions and the origins of the chiropractic profession.

RESULTS

The AMA began in the mid-1800s to unify like-minded "regular" medical physicians who developed a code of ethics and promoted higher educational standards. Their efforts to unify had excluded other types of health care providers, which they called "irregular" practitioners. However, Americans were seeking more natural alternatives to the harsh methods that regular medical physicians offered at that time. Nearly 50 years after the AMA began, the chiropractic profession attempted to emerge during a time when many patients valued vitalism and their freedom to choose what health care provider they would access.

CONCLUSION

During the years that chiropractic developed as a healing profession, organized medicine was already well established and developing a monopoly in American health care. These events created the foundation on which the tensions between these professions were built and ultimately resulted in the Wilk v AMA lawsuit.

Looking back at the lawsuit that transformed the chiropractic profession part 7: Lawsuit and decisions

OBJECTIVE

This is the seventh paper in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to provide a summary of the lawsuit that was first filed in 1976 and concluded with the final denial of appeal in 1990.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive time line. This paper, the seventh of the series, considers the information of the 2 trials and the judge's decision.

RESULTS

By the time the first trial began in 1980, the AMA had already changed its anti-chiropractic stance to allow medical doctors to associate with chiropractors if they wished. In the first trial, the chiropractors were not able to overcome the very stigma that organized medicine worked so hard to create over many decades, which resulted in the jury voting in favor of the AMA and other defendants. The plaintiffs, Drs Patricia Arthur, James Bryden, Michael Pedigo, and Chester Wilk, continued with their pursuit of justice. Their lawyer, Mr George McAndrews, fought for an appeal and was allowed a second trial. The second trial was a bench trial in which Judge Susan Getzendanner declared her final judgment that "the American Medical Association (AMA) and its members participated in a conspiracy against chiropractors in violation of the nation's antitrust laws." After the AMA's appeal was denied by the Court of Appeals for the Seventh Circuit in 1990, the decision was declared permanent. The injunction that was ordered by the judge was published in the January 1, 1988, issue of the Journal of the American Medical Association.

CONCLUSION

The efforts by Mr McAndrews and his legal team and the persistence of the plaintiffs and countless others in the chiropractic profession concluded in Judge Getzendanner's decision, which prevented the AMA from rebuilding barriers or developing another boycott. The chiropractic profession was ready to move into its next century.

Looking back at the lawsuit that transformed the chiropractic profession part 3: Chiropractic growth

OBJECTIVE

This is the third paper in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to provide a brief review of the history of the growth of chiropractic, its public relations campaigns, and infighting that contributed to the events surrounding the Wilk v AMA lawsuit.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive timeline. This paper is the third of the series that explores the growth the chiropractic profession.

RESULTS

By the 1930s, the AMA was already under investigation for violation of antitrust laws and the National Chiropractic Association was suggesting that the AMA was establishing a health care monopoly. Chiropractic schools grew and the number of graduates rose quickly. Public relations campaigns and publications in the popular press attempted to educate the public about chiropractic. Factions within the profession polarized around differing views of how they thought that chiropractic should be practiced and portrayed to the public. The AMA leaders noted the infighting and used it to their advantage to subvert chiropractic.

CONCLUSION

Chiropractic grew rapidly and established its presence with the American public through public relations campaigns and popular press. However, infighting would give the AMA material to further its efforts to contain and eliminate the chiropractic profession.

Looking back at the lawsuit that transformed the chiropractic profession part 8: Judgment impact

OBJECTIVE

This paper is the eighth in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to discuss the possible impact that the final decision in favor of the plaintiffs may have had on the chiropractic profession.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive timeline. This paper is the eighth of the series that discusses how the trial decision may have influenced the chiropractic that we know today in the United States.

RESULTS

Chiropractic practice, education, and research have changed since before the lawsuit was filed. There are several areas in which we propose that the trial decision may have had an impact on the chiropractic profession.

CONCLUSION

The lawsuit removed the barriers that were implemented by organized medicine against the chiropractic profession. The quality of chiropractic practice, education, and research continues to improve and the profession continues to meet its most fundamental mission: to improve the lives of patients. Chiropractors practicing in the United States today are allowed to collaborate freely with other health professionals. Today, patients have the option to access chiropractic care because of the dedicated efforts of many people to reduce the previous barriers. It is up to the present-day members of the medical and chiropractic professions to look back and to remember what happened. By recalling the events surrounding the lawsuit, we may have a better understanding about our professions today. This information may help to facilitate interactions between medicine and chiropractic and to develop more respectful partnerships focused on creating a better future for the health of the public. The future of the chiropractic profession rests in the heads, hearts, and hands of its current members to do what is right.

Looking back at the lawsuit that transformed the chiropractic profession part 5: Evidence exposed

OBJECTIVE

This is the fifth article in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this article is to provide a brief review of events surrounding the eventual end of the AMA's Committee on Quackery and the exposure of evidence of the AMA's efforts to boycott the chiropractic profession.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 articles following a successive timeline. This article, the fifth of the series, explores the exposure of what the AMA had been doing, which provided evidence that was eventually used in the Wilk v AMA antitrust lawsuit.

RESULTS

The prime mission of the AMA's Committee on Quackery was "first, the containment of chiropractic and, ultimately, the elimination of chiropractic." However, the committee did not complete its mission and quietly disbanded in 1974. This was the same year that the chiropractic profession finally gained licensure in all 50 of the United States; received recognition from the US Commissioner of Education, Department of Health, Education and Welfare; and was successfully included in Medicare. In 1975, documents reportedly obtained by the Church of Scientology covert operatives under Operation AMA Doom revealed the extent to which the AMA and its Committee on Quackery had been working to contain and eliminate the chiropractic profession. The AMA actions included influencing mainstream media, decisions made by the Joint Commission on Accreditation of Hospitals, and the Department of Health, Education, and Welfare. Other actions included publishing propaganda against chiropractic and implementing an anti-chiropractic program aimed at medical students, medical societies, and the American public.

CONCLUSION

After more than a decade of overt and covert actions, the AMA chose to end its Committee on Quackery. The following year, documents exposed the extent of AMA's efforts to enact its boycott of chiropractic.

Full-Coverage Chiropractic in Medicare: A Proposal to Eliminate Inequities, Improve Outcomes, and Reduce Health Disparities Without Increasing Overall Program Costs

OBJECTIVE

The purpose of this article is to discuss evidence that supports the resolution of inequities for Medicare beneficiaries who receive chiropractic care.

DISCUSSION

Medicare covers necessary examinations, imaging, exercise instruction, and treatments for beneficiaries with back pain when provided by medical doctors, osteopaths, and their associated support staff such as nurse practitioners, physician assistants, clinical nurse specialists, and physical therapists. However, if the same patient with back pain presents to a chiropractor, then the only service that is covered by Medicare is manipulation of the spine. Current evidence does not support this inequity in Medicare beneficiary service coverage. There is no evidence to show an increase in serious risks associated with chiropractic treatment of neck or back pain in Medicare beneficiaries. Chiropractors support national public health goals and endorse safe, evidence-based practices. Chiropractic care for Medicare beneficiaries has been associated with enhanced clinical outcomes such as faster recovery, fewer back surgeries a year later, reduced opioid-associated disability, fewer traumatic injuries and falls, and slower declines in activities of daily living and disability over time. Further evidence points to lower costs, fewer medical physician visits for low back pain, less opioid-related expense, and less back-surgery expense with chiropractic utilization. Use is lower among vulnerable populations: seniors, lower income women, and black and Hispanic beneficiaries who may be most affected by current inequities associated with the limited coverage. In this era of evidence-based and patient-centered care, beneficiaries who receive chiropractic care are very satisfied with the care they receive.

CONCLUSION

The current evidence suggests a need for change in US policy toward chiropractic in Medicare and support for HR 3654. Ending inequities by providing patients full coverage for chiropractic services has the potential to enhance care outcomes and reduce health disparities without increasing program costs.

Chiropractic Day: A Historical Review of a Day Worth Celebrating

OBJECTIVE

The purpose of this paper is to review and discuss historical concepts about the celebration of Chiropractic Day.

DISCUSSION

Daniel David Palmer attributed September 18, 1895 to be the day that he delivered the first chiropractic adjustment. As the chiropractic profession grew, the celebration of Chiropractic Day became more widespread throughout the United States and the world. This paper offers suggestions about how to celebrate Chiropractic Day. Activities include educating, learning, honoring, volunteering, and engaging.

CONCLUSION

The chiropractic profession celebrates its birth on September 18. Regardless of the many different names used over the past 125 years, including Chiropractic Founder's Day, Chiropractic Rally Day, Chiropractic Anniversary, and Chiropractic Discovery Day, the celebration of this special day provides an opportunity to reflect on how far the profession has come and how chiropractors continue to help and serve their patients.

Response of Practicing Chiropractors during the Early Phase of the COVID-19 Pandemic: A Descriptive Report

Objective

The coronavirus disease-2019 (COVID-19) pandemic has strained all levels of healthcare and it is not known how chiropractic practitioners have responded to this crisis. The purpose of this report is to describe responses by a sample of chiropractors during the early stages of the COVID-19 pandemic.

Methods

We used a qualitative-constructivist design to understand chiropractic practice during the COVID-19 pandemic, as described by the participants. A sample of chiropractic practitioners (doctors of chiropractic, chiropractors) from various international locations were invited to participate. Each described the public health response to COVID-19 in their location and the actions that they took in their chiropractic practices from April 20 through May 4, 2020. A summary report was created from their responses and common themes were identified.

Results

Eighteen chiropractic practitioners representing 17 locations and 11 countries participated. A variety of practice environments were represented in this sample, including, solo practice, mobile practice, private hospital, US Veterans Administration health care, worksite health center, and group practice. They reported that they recognized and abided by changing governmental regulations. They observed their patients experience increased stress and mental health concerns resulting from the pandemic. They adopted innovative strategies, such as telehealth, to do outreach, communicate with, and provide care for patients. They abided by national and World Health Organization recommendations and they adopted creative strategies to maintain connectivity with patients through a people-centered, integrated, and collaborative approach.

Conclusion

Although the chiropractors in this sample practiced in different cities and countries, their compliance with local regulations, concern for staff and patient safety, and people-centered responses were consistent. This sample covers all 7 World Federation of Chiropractic regions (ie, African, Asian, Eastern Mediterranean, European, Latin American, North American, and Pacific) and provides insights into measures taken by chiropractors during the early stages of the COVID-19 pandemic. This information may assist the chiropractic profession as it prepares for different scenarios as new evidence about this disease evolves.

Response of Chiropractic Organizations to the COVID-19 Pandemic: A Descriptive Report

Objective

The purpose of this report is to describe actions by chiropractic entities during the early stages of the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Large entities that support chiropractic education or practice were invited to participate in this report. Leaders of various entities were emailed an invitation. A designee who was assigned by the leader provided a brief synopsis of actions the entity had taken in response to the COVID-19 pandemic. Only entities that responded are included in this report.

Results

Five entities agreed to participate: The Council on Chiropractic Education, Association of Chiropractic Colleges, Federation of Chiropractic Licensing Boards, National Board of Chiropractic Examiners, and the National Chiropractic Mutual Insurance Company. Common themes included (1) recognizing the crisis and taking action, (2) establishing a safe working environment for staff so that services could continue, (3) delivering communications to stakeholders (chiropractic students, practitioners, licensing boards, and others) to guide decisions and direct actions, and (4) continuing to monitor the situation and respond as new information becomes available.

Conclusion

These entities serve a large portion of the chiropractic profession. They have been quick to respond in a responsible, compassionate, and supportive manner to assist chiropractic licensing boards, practitioners, and students during the COVID-19 pandemic. These findings are encouraging as the chiropractic profession looks to the future as it navigates changes in education and the health care environment in the months and years ahead.

Words matter: the prevalence of chiropractic-specific terminology on Australian chiropractors' websites

BACKGROUND

Chiropractors use words and phrases in unique ways to express traditional, chiropractic-specific theories. This lexicon represents concepts that reinforce the separation of chiropractic from other health care professions. It may impact referrals both to and from chiropractors, lead to public confusion about health care issues, and reduce cross-disciplinary research. Therefore, it is important to understand how prevalent chiropractic-specific terms are in publicly available media.

METHODS

Five chiropractic terms were selected: subluxation, adjustment, vital (-ism/-istic), wellness, and Innate (Intelligence). States and territories in Australia were proportionately sampled according to population of chiropractors using a Google search for chiropractors' private practice websites. The top results were recorded. Websites were word-searched on every publicly available page for the five terms. Context was checked to count only terms that were used to support a chiropractic-specific concepts. The number of occurrences of each term was recorded, tallied nationally and by state/territory. Descriptive statistics were applied to determine prevalence.

RESULTS

Three hundred sixty-nine websites were sampled, based on an estimate of 5500 chiropractors practising in Australia. Nationally, 85% of chiropractors used one or more terms. The term adjust (-ing/-ment) occurred most frequently, being found on 283 websites (77%) with a total of 2249 occurrences. Wellness was found on 199 websites (54%) with 872 occurrences; subluxation was found on 104 websites (28%), 489 occurrences; vital (-ism/-istic) on 71 websites (19%) with 158 occurrences; and Innate was least used, being found on 39 websites (11%) with 137 occurrences.

CONCLUSION

A majority of the Australian chiropractors sampled used one or more chiropractic-specific terms on their websites. Future research should explore the effects of chiropractic language on the public, policy-makers, and other health care professionals.

Association between media attention and presentation of vaccination information on Canadian chiropractors' websites: a prospective mixed-methods cohort study

BACKGROUND

Historically, some chiropractors have been critical of vaccination, and this has been the subject of recent media attention in Canada. We explored the association between media attention and public dissemination of vaccination information on Canadian chiropractors' websites.

METHODS

In 2016, we identified all Canadian chiropractors' websites that provided information on vaccination by extracting details from the regulatory college website for each province using the search engine on their "find a chiropractor" page. We assessed the quality of information using the Web Resource Rating Tool (scores range from 0% [worst] to 100% [best]), determined whether vaccination was portrayed in a positive, neutral or negative manner, and conducted thematic analysis of vaccination content. We revisited all identified websites in 2019 to explore for changes to posted vaccination material.

RESULTS

In July 2016, of 3733 chiropractic websites identified, 94 unique websites provided information on vaccination: 59 (63%) gave negative messaging, 19 (20%) were neutral and 16 (17%) were positive. The quality of vaccination content on the websites was generally poor, with a median Web Resource Rating Tool score of 19%. We identified 4 main themes: there are alternatives to vaccination, vaccines are harmful, evidence regarding vaccination and health policy regarding vaccination. From 2012 to 2016, there was 1 Canadian newspaper story concerning antivaccination statements by chiropractors, whereas 51 news articles were published on this topic between 2017 and 2019. In April 2019, 45 (48%) of the 94 websites we had identified in 2016 had removed all vaccination content or had been discontinued.

INTERPRETATION

In 2016, a minority of Canadian chiropractors provided vaccination information on their websites, the majority of which portrayed vaccination negatively. After substantial national media attention, about half of all vaccination material on chiropractors' websites was removed within several years.

Doing the Same Thing and Expecting a Different Outcome: It Is Time for a Questioning Philosophy and Theory-Driven Chiropractic Research

OBJECTIVE

The purpose of this commentary is to discuss the philosophical and hypothetical underpinnings of chiropractic and consider whether there is a need for chiropractic to have a questioning philosophy and theory-driven process to guide future scientific endeavors in the profession.

DISCUSSION

The earliest beliefs of the chiropractic founders centered on chiropractic vertebral subluxation but differed on whether this was a static, bone-out-of-place misalignment or a lesion whereby joints had lost their normal direction or range of motion. More recently, new hypotheses such as dyskinesia, inflammation, and neuroplasticity attempt to explain the purported clinical effects of chiropractic. Yet practitioners and students advocate for both traditional viewpoints that typically tout misalignment and embrace a science of chiropractic. I propose that chiropractors should not have to choose between philosophy and science. Instead, they should advocate for adoption of a modern questioning philosophy that not only informs their clinical questions and drives their theories, but also that is in turn influenced by outcomes from their research. Such a questioning philosophy is in stark contrast with the dogma that some have mislabeled as "philosophy" in the profession. I recommend that a review of chiropractic hypotheses and a theory-driven research process is needed to help guide the profession's research agenda given its wide range of clinical activities and limited resources. As the chiropractic profession increasingly embraces evidence-informed practice, enhanced integration within the wider health care community may then result in further gains in utilization.

CONCLUSION

Theory-driven research that results from and subsequently informs a questioning philosophy may expose truths related to practice behaviors, activities, and outcomes, and spur more complete integration of chiropractic within the wider health care community.

Newly qualified chiropractors' perceptions of preparedness for practice: A cross-sectional study of graduates from European training programs

OBJECTIVE

The purpose of this pilot study was to explore chiropractic graduates' perceived preparedness for practice in the 7 key competencies of the Canadian Medical Education Directives for Specialists.

METHODS

An anonymous 5-point Likert scale electronic questionnaire was distributed to graduates from the 2014-2016 cohorts of 9 European chiropractic colleges accredited by the European Council of Chiropractic Education. For each group under 1 competency role, the mean overall score was calculated. Statistical differences were analyzed using a t test and analysis of variance. Cronbach's alpha was calculated for internal consistency.

RESULTS

Results of 7 chiropractic colleges were analyzed (n = 121). Differences were found among colleges, competencies, and items. Overall, the graduates who responded scored the lowest in collaborator (3.76) and scholar (3.78) competencies. They scored the highest in professional (4.39) and chiropractic expert (4.13) competencies. In all colleges, a lower level of perceived preparedness was found in collaborator, scholar, and manager competencies. Statistical differences were found that compared the type of employment and cohorts.

CONCLUSION

Our results show there may be a gap between education and professional practice regarding perceived preparedness, and graduates perceived themselves to be unprepared in some competencies. The preliminary results of this study could be used to improve curricula of chiropractic education.

The biopsychosocial model and chiropractic: a commentary with recommendations for the chiropractic profession

There is an increasing awareness, interest and acceptance of the biopsychosocial (BPS) model by all health care professionals involved with patient care. The areas of spine care and pain medicine are no exception, and in fact, these areas of health care are a major centerpiece of the movement from the traditional biomedical model to a BPS model of patient assessment and delivery of care. The chiropractic approach to health care has a history that is grounded in key aspects of the BPS model. The profession has inherently implemented certain features of the BPS model throughout its history, perhaps without a full understanding or realization. The purpose of this paper is to present an overview of the BPS model, its relationship with spine care and pain management, and to discuss the BPS model, particularly psychosocial aspects, in the context of its historical relationship with chiropractic. We will also provide recommendations for the chiropractic profession as it relates to successful adoption of a full integration of the BPS model.

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.

Chiropractic intern attitudes, beliefs, and future practice intentions with regard to health promotion, wellness, and preventive services

OBJECTIVE

This pilot study explored the attitudes, beliefs, and intentions of a group of chiropractic interns concerning health promotion, wellness, and preventive services before and after a series of brief educational interventions.

METHODS

Interns completed a survey before (n = 37) and after (n = 22) the interventions. The survey included 12 Likert scale questions about attitudes and intentions toward wellness and health promotion models. The interventions consisted of classroom lectures, clinical training, and online information pertaining to health promotion and wellness.

RESULTS

The interns initially favored wellness models, perceived a need for them, and felt partially prepared to administer them, with mean Likert scores 4 or greater on a 1 to 5 scale. Afterward, the average scores were higher and the interns reported some benefit from this short course of training.

CONCLUSION

The initial survey demonstrated that interns had some understanding of wellness, health promotion, and preventive services, and favored utilization of these services. The follow-up survey suggested that a short educational intervention could have a positive impact on these attitudes and future utilization of wellness procedures in their practices.

Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. A systematic search of Medline, CINAHL, and Index to Chiropractic Literature was performed from inception through April 2015. Thirty articles met inclusion criteria. Studies reporting utilization and policy show that chiropractic services are successfully implemented in various military and veteran health care settings and that integration varies by facility. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.

Effects of Expanded Coverage for Chiropractic Services on Medicare Costs in a CMS Demonstration

BACKGROUND

Moderately convincing evidence supports the benefits of chiropractic manipulations for low back pain. Its effectiveness in other applications is less well documented, and its cost-effectiveness is not known. These questions led the Centers for Medicaid and Medicare Services (CMS) to conduct a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head.

METHODS

The demonstration was conducted in 2005-2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework.

RESULTS

Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa.

CONCLUSION

The demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.

The McAndrews Leadership Lecture: February 2015, by Dr Scott Haldeman. Challenges of the Past, Challenges of the Present

The McAndrews Leadership Lecture was developed by the American Chiropractic Association to honor the legacy of Jerome F. McAndrews, DC, and George P. McAndrews, JD, and their contributions to the chiropractic profession. This article is a transcription of the presentation made by Dr Scott Haldeman on February 28, 2015, in Washington, DC, at the National Chiropractic Leadership Conference.

Weight gain as a consequence of living a modern lifestyle: a discussion of barriers to effective weight control and how to overcome them

OBJECTIVE

The purpose of this commentary is to discuss modern lifestyle factors that promote weight gain and to suggest methods for clinicians to more effectively educate patients about weight management.

DISCUSSION

Most adults in the United States are overweight or obese. Multiple factors related to the modern lifestyle appear to play causal roles. In general, the population maintains sedentary lives and overconsumes calorie-dense foods. In particular, refined carbohydrates negatively impact metabolism and stimulate neural addiction mechanisms, which facilitate weight gain. As adipose tissue mass accumulates, satiation centers in the hypothalamus become resistant to insulin and leptin, which leads to increased caloric consumption. Several behavior issues further augment weight gain, such as eating too quickly, a lack of sleep, high stress levels, and a lack of exercise. Finally, adipose tissue accumulation alters the body weight set point, which leads to metabolic changes that function to resist weight loss efforts. Each of these factors may work together to augment weight gain and promote obesity. Health care providers, such as chiropractic physicians, who educate patients on wellness, prevention, and lifestyle changes are well positioned to address these issues.

CONCLUSION

People need to be educated about the modern lifestyle factors that prevent effective weight management. Without this knowledge and the associated practical application of lifestyle choices that prevent weight gain, becoming overweight or obese appears to be an unavoidable consequence of living a modern lifestyle.

Embedding chiropractic in Indigenous Health Care Organisations: applying the normalisation process model

Background

Improving the health of Indigenous Australians remains a major challenge. A chiropractic service was established to evaluate this treatment option for musculoskeletal illness in rural Indigenous communities, based on the philosophy of keeping the community involved in all the phases of development, implementation, and evaluation. The development and integration of this service has experienced many difficulties with referrals, funding and building sustainability. Evaluation of the program was a key aspect of its implementation, requiring an appropriate process to identify specific problems and formulate solutions to improve the service.

Methods

We used the normalisation process model (May 2006) to order the data collected in consultation meetings and to inform our strategy and actions. The normalisation process model provided us with a structure for organising consultation meeting data and helped prioritise tasks. Our data was analysed as it applied to each dimension of the model, noting aspects that the model did not encompass. During this process we reworded the dimensions into more everyday terminology. The final analysis focused on to what extent the model helped us to prioritise and systematise our tasks and plans.

Results

We used the model to consider ways to promote the chiropractic service, to enhance relationships and interactions between clinicians and procedures within the health service, and to avoid disruption of the existing service. We identified ways in which chiropractors can become trusted team members who have acceptable and recognised knowledge and skills. We also developed strategies that should result in chiropractic practitioners finding a place within a complex occupational web, by being seen as similar to well-known occupations such as physiotherapy. Interestingly, one dimension identified by our data, which we have labelled ‘emancipatory’, was absent from the model.

Conclusions

The normalisation process model has resulted in a number of new insights and questions. We have now established thriving weekly chiropractic clinics staffed by a team of volunteer chiropractors. We identified an ‘emancipatory’ dimension that requires further study. We provide a worked example of using this model to establish, integrate and evaluate a chiropractic service in an Indigenous Australian community.

Consensus process to develop a best-practice document on the role of chiropractic care in health promotion, disease prevention, and wellness

OBJECTIVE

The purposes of this project were to develop consensus definitions for a set of best practices that doctors of chiropractic may use for promoting health and wellness and preventing disease and to describe the appropriate components and procedures for these practices.

METHODS

A multidisciplinary steering committee of 10 health care professionals developed seed statements based on their clinical experience and relevant literature. A Delphi consensus process was conducted from January to July 2011, following the RAND methodology. Consensus was reached when at least 80% of the panelists were in agreement. There were 44 Delphi panelists (36 doctors of chiropractic, 6 doctors of philosophy, 1 doctor of naturopathy, 1 registered nurse).

RESULTS

The statements developed defined the terms and practices for chiropractic care to promote health and wellness and prevent disease.

CONCLUSION

This document describes the procedures and features of wellness care that represent a reasonable approach to wellness care and disease prevention in chiropractic clinical practice. This living document provides a general framework for an evidence-based approach to chiropractic wellness care.

Influenza vaccination among chiropractic patients and other users of complementary and alternative medicine: are chiropractic patients really different?

OBJECTIVE

Previous studies suggest a possible association between using chiropractic care and lower influenza vaccination rates. We examined adult influenza vaccination rates for chiropractic patients to determine if they are different than those for users of other complementary and alternative medicine (CAM).

METHOD

We used the 2007 National Health Interview Survey to examine influenza vaccination rates among adult respondents who were considered high priority for the influenza vaccine (n=12,164). We separated respondents into clinically meaningful categories according to age and whether or not they had recently used chiropractic care, some other type of CAM, or neither. We used adjusted logistic regression to determine whether user status predicted influenza vaccination.

RESULTS

Only 33% of younger and 64% of older high priority Chiropractic Users were vaccinated in 2007; these rates approximated those of Non-CAM Users. However, younger Non-Chiropractic CAM Users were more likely than Non-CAM Users to have been vaccinated (p-value=0.05). In adjusted logistic regressions, we found statistically insignificant differences when comparing Chiropractic Users to Non-CAM Users for younger adults (OR=0.93(95% CI:0.76-1.13), or for older adults OR=0.90 (95% CI:0.64-1.20).

CONCLUSION

Chiropractic Users appear no less likely to be vaccinated for influenza; whereas, younger Non-chiropractic CAM Users are more likely than Non-CAM Users to be vaccinated.

A survey of wellness management strategies used by Canadian doctors of chiropractic

OBJECTIVE

The purpose of this study was to investigate if Canadian doctors of chiropractic consider using wellness strategies after functional recovery in acute and chronic conditions. This study also attempted to determine if there is a difference in the use of wellness management strategies between broad and narrow scope practitioners.

METHODS

Forty-one practicing, licensed chiropractors were recruited to complete an interview survey regarding 2 mock clinical case presentations. Interviews were recorded, and influential words or word pairings were identified. Investigators formulated criteria to divide practitioners into broad scope (mixers) and narrow scope (straights). Data were analyzed using Crawdad Analysis Software (version 1.2).

RESULTS

All subjects indicated that they would provide information regarding public health and wellness strategies to a patient after functional resolution of the presenting chronic or acute complaints. The responses of broad scope (mixer) chiropractors appeared to be focused on the patient specifically, whereas narrow scope (straight) responses appeared to be more varied when analyzed for noun and noun-pair influence.

CONCLUSION

This study of practicing, licensed Canadian chiropractors suggests that wellness strategies may be commonly considered in practice. All subjects in this study reported a number of strategies to educate patients regarding wellness after functional recovery of a complaint.

Familiarity with and advocacy of Healthy People 2010 goals by Mississippi Chiropractic Association members

OBJECTIVE

The purpose of this study was to determine the familiarity with and stated advocacy of Healthy People 2010 objectives by member doctors of the Mississippi Chiropractic Association.

METHODS

Peer experts established face validity of a questionnaire regarding the Leading Health Indicators. This survey was distributed to 157 Mississippi Chiropractic Association members in 2009 during a conference and a follow-up by postal mail.

RESULTS

Most doctors of chiropractic in the sample (n = 68, or 43% response) consider themselves wellness-oriented health care providers. Forty-two percent had read, 29% had not read, and another 29% were unsure whether they had read the Healthy People 2010 national objectives. Almost half (44%) strongly or somewhat agreed that their office practice reflects support for the Healthy People 2010 objective. In contrast, 27% disagree and 29% were unsure if their practice reflects the Healthy People 2010 objectives. There were differences between support and practice behaviors for some of the objectives. Chiropractors who have read the objectives tend to be more supportive of the national goals. Doctors of chiropractic in this sample are supportive of most Leading Health Indicators, and the majority reports that they incorporate these public health goals into their practices.

CONCLUSION

Familiarity with reading the Health People objectives seems to be related to reported practice behaviors. There is a need to improve the percentage of practicing doctors of chiropractic who are familiar with Healthy People objectives. Future health education initiatives may assist doctors of chiropractic in further incorporating public health objectives into their practice behaviors and improving quality health care.

The sustainable training, treatment, employment program model: effects of manual therapy on musculoskeletal pain and limitation in a Filipino squatter community

OBJECTIVE

The purpose of this study is to describe the musculoskeletal conditions and associated pain and limitation and the effects of massage treatment in a Filipino squatter community.

METHODS

The study was conducted at the Hands On Philippines Education (HOPE) clinic in Bagong Barrio, Caloocan, Philippines. Baseline data were collected before the first treatment, and follow-up data were collected immediately after the second treatment. Treatment was delivered by massage students who were trained in massage by a chiropractic program faculty member through the Project HOPE charitable community-based initiative. A prospective pretest-posttest observational research design was used. The sample consisted of 290 subjects aged 16 years and older visiting the Project HOPE clinic. One hundred ninety-two subjects completed the follow-up surveys. The outcome measures were sites of pain, self-reported levels of pain, and limitation to activities of daily living at baseline and after the second massage therapy treatment.

RESULTS

Three self-reported anatomical locations were identified by each subject. The most frequently reported painful sites over the last 7 days among the 166 respondents were the upper back (36.7%), lower back (18.7%), and shoulders (16.3%). The pre-post treatment analyses of pain and disability was restricted to 66 participants who provided completed outcome measures. After 2 massage therapy treatments, all pain and limitation scores decreased. A comparison of mean self-reported levels of pain and disability at baseline and immediately after the second consultation showed statistically significant decreases of pain (t65 = 16.97, P < .001) and disability (t65 = 12.4, P < .001).

CONCLUSION

This study suggests that participants who visited the Filipino squatter community clinic experience a high prevalence of musculoskeletal conditions located primarily within the axial skeleton, and that, in the short term, massage therapy delivered on-site by trained therapists was helpful in reducing self-reported levels of pain and limitation to activities of daily living.

Chiropractic at the crossroads or are we just going around in circles?

Background

Chiropractic in Australia has seen many changes over the past 30 years. Some of these changes have advanced the professional status of chiropractic, improved undergraduate training and paved the way for a research culture. Unfortunately, other changes or lack of changes, have hindered the growth, public utilisation and professional standing of chiropractic in Australia. This article explores what influences have impacted on the credibility, advancement and public utilisation of chiropractic in Australia.

Discussion

The 1970's and 1980's saw a dramatic change within the chiropractic profession in Australia. With the advent of government regulation, came government funded teaching institutions, quality research and increased public acceptance and utilisation of chiropractic services. However, since that time the profession appears to have taken a backward step, which in the author's opinion, is directly linked to a shift by sections of the profession to the fundamentalist approach to chiropractic and the vertebral subluxation complex. The abandonment, by some groups, of a scientific and evidenced based approach to practice for one founded on ideological dogma is beginning to take its toll.

Summary

The future of chiropractic in Australia is at a crossroads. For the profession to move forward it must base its future on science and not ideological dogma. The push by some for it to become a unique and all encompassing alternative system of healthcare is both misguided and irrational.

Caught in the crosshairs: identity and cultural authority within chiropractic

In this paper the discourse over identity and cultural authority within the profession of chiropractic in the United States has been analyzed using critical discourse analysis. As the profession struggles to construct one singular image, versions of self must be internally debated and also shaped in consideration of larger, external forces. The dilemma of remaining tied to a marginal professional status must be balanced against considerations of integration. Written texts from chiropractic journals and newspapers are analyzed in a multidimensional approach that considers the rhetorical devices and thematic issues of identity construction; the representation of various voices within the discourse (both heard and unheard); and the extent to which external pressures affect the projection of cultural authority for the profession. A heterogeneous discourse characterized by conflict was found, with discrepancies between everyday chiropractors in actual practice versus academic chiropractors and leaders particularly over the idea, practice and significance of science for the profession.

Could chiropractors screen for adverse drug events in the community? Survey of US chiropractors

BACKGROUND

The "Put Prevention into Practice" campaign of the US Public Health Service (USPHS) was launched with the dissemination of the Clinician's Handbook of Preventive Services that recommended standards of clinical care for various prevention activities, including preventive clinical strategies to reduce the risk of adverse drug events. We explored whether nonprescribing clinicians such as chiropractors may contribute to advancing drug safety initiatives by identifying potential adverse drug events in their chiropractic patients, and by bringing suspected adverse drug events to the attention of the prescribing clinicians.

METHODS

Mail survey of US chiropractors about their detection of potential adverse drug events in their chiropractic patients.

RESULTS

Over half of responding chiropractors (62%) reported having identified a suspected adverse drug event occurring in one of their chiropractic patients. The severity of suspected drug-related events detected ranged from mild to severe.

CONCLUSIONS

Chiropractors or other nonprescribing clinicians may be in a position to detect potential adverse drug events in the community. These detection and reporting mechanisms should be standardized and policies related to clinical case management of suspected adverse drug events occurring in their patients should be developed.

Health care transitions: a review of integrated, integrative, and integration concepts

In this article, several views of the terms integration, integrated, and integrative are considered with the hopes that this brief review will help to raise awareness, clarify various uses of these terms, and add to the continuing discussion of integration and how we might improve health care. Models of integrative care, views of integration, and samples of different interpretations and definitions are offered.

The difference between integration and collaboration in patient care: results from key informant interviews working in multiprofessional health care teams

OBJECTIVES

Despite the growing interest in integrative health care, collaborative care, and interdisciplinary health care teams, there appears to be little consistency in terminology and clarity regarding the goal for these teams, other than "working together" for the good of the patients. The purpose of this study was to explore what the terms integration and collaboration mean for practitioners and other key informants working in multiprofessional health care teams, with a specific look at chiropractic and family physician teams in primary care settings.

METHODS

Semistructured interviews were conducted with 16 key informants until saturation was obtained in the key emerging themes. All interviews were audiorecorded, and the transcripts were coded using qualitative content analysis.

RESULTS

Most participants differentiated collaboration from integration. They generally described a model of professions working closely together (ie, collaborating) in the delivery of care but not subsumed into a single organizational framework (ie, integration). Our results suggest that integration requires collaboration as a precondition but collaboration does not require integration.

CONCLUSIONS

Collaboration and integration should not be used interchangeably. A critical starting point for any new interdisciplinary team is to articulate the goals of the model of care.