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Research Review By Dr. Ceara Higgins©


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Date Posted:

October 2017

Study Title:

Primary prevention in chiropractic practice: a systematic review


Goncalves G, Le Scanff C, Leboeuf-Yde C

Author's Affiliations:

IAMS, University of Paris-Sud, University of Paris-Saclay, Orsay Cedex, France; CIAMS, University of Orleans, France; Institut Franco Europeen de Chiropraxie, Ivry sur Seine, France

Publication Information:

Chiropractic & Manual Therapies 2017; 25: 9-30.

Background Information:

Non-communicable diseases, both musculoskeletal and non-MSK, create a social and economic burden because they can lead to long-term disability, morbidity and mortality (1). As such, preventing these conditions could confer numerous benefits to patients and society in general. There are three types of prevention: 1) primary prevention (PP) – preventing disease in healthy individuals; 2) secondary prevention – preventing a condition from recurring; and 3) tertiary prevention – maintaining an irreversible chronic condition at a reasonable level (2).

As chiropractors are recognized as primary health care practitioners in many areas of the world, a public health approach, including health promotion, should be included in the curriculum in chiropractic undergraduate programs (3). The World Health Organization states that “Chiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the musculoskeletal system and the effects of these disorders on general health” (4). As well, some health-related issues that are not purely musculoskeletal are suitable to address in a primary care setting. These include lifestyle issues such as nutrition, physical activity, stress management, and even screening for skin cancers as chiropractic patients are often partially undressed during examination and/or treatment.

Some chiropractors believe that spinal dysfunction can be detected reliably in both asymptomatic and symptomatic spines, and that chiropractic manipulation can improve this dysfunction, leading to a positive effect on both current and future back pain as well as favorable effects on general health, well-being and disease prevention (5).

This systematic review aimed to answer three questions:
  1. What is the prevalence of chiropractors with positive opinions of the use of PP?
  2. What is the prevalence of chiropractors who use PP?
  3. What is the proportion of chiropractic patients who consult for PP?
The authors attempted to deal with each of these questions from the angles of musculoskeletal conditions, public health issues, and wellness (defined as PP through chiropractic care).

Pertinent Results:

25 articles were included in this review. Of those, 5 studied prevention, 15 studied chiropractors’ use or opinions of PP, with 13 of those targeting patients and 9 of them dealing with specific chiropractic interest groups, such as individuals specializing in pediatric treatments. The reviewers classified 11 studies as “good”, 9 as “acceptable”, and 6 as “unacceptable”.

In articles where chiropractors were the source of information on PP, 7 studies looked at their opinions on PP and 12 looked at the prevalence of chiropractors using PP in their practices. 19 studies looked at PP in relation to wellness, 8 looked at PP in relation to public health, and 9 looked at the PP of musculoskeletal (MSK) conditions. The reviewers selected 5 topics for analysis:
  1. Prescription of dietary supplements or advice on nutrition
  2. Prescription of, or advice on, physical activity
  3. Advice on tobacco cessation
  4. Detection of skin lesions
  5. Non-specific public health
Chiropractors’ opinions on PP for general public health were covered in 2 “good” studies (6, 10), with around 90% of chiropractors reporting positive opinions on physical activity prescription or nutritional advice. Almost 70% of chiropractors expressed positive opinions on tobacco cessation advice and between 57% and 81% expressed positive opinions on skin lesion detection depending on how the question was asked. One “good” study showed that 92% of chiropractors reported being wellness-oriented (10) but one “acceptable” study only showed 8% that were focused on wellness/prevention (12). Two “good” studies defined wellness as the treatment of spinal “subluxation” and found that 19% of chiropractors, classified by the author of that study as “unorthodox”, considered the “chiropractic subluxation as an obstruction to human health” (9), while 93% of chiropractors in the second study expressed a positive attitude toward “subluxation screening” (6).

Three studies looked at PP of MSK disorders. In one “good” study, 90% of chiropractors reported providing information on the prevention of MSK disorders (6), while one “acceptable” study showed 96% of chiropractors provided advice on posture and 88% provided advice on movement patterns (13). A second “acceptable” study reported that more than 70% of chiropractors provided treatment for “spinal health maintenance/prevention” without specifying the type of prevention (14).

Seven articles looked at public health advice and screening procedures included in chiropractic consultations. Two “good” studies showed that 86% and 82% of chiropractors provided nutritional advice (6, 8), while 2 “acceptable” studies reported the rates at 77% and 79%, respectively (13, 15). Two “good” (6,10) and one “acceptable” (13) study reported that about 90% of chiropractors prescribed or advised patients on physical activity. These articles also reported on advice on tobacco cessation, with around 60% of chiropractors reporting providing this type of advice. Skin cancer screening was covered in 2 “good” articles with 50% of chiropractors reporting performing these types of screenings with no frequency reported (6) in one article, and 53% reporting screening at every visit and 94% reporting screening all new patients (11).

One “good” study (16) found that more than 90% of chiropractors performed periodic maintenance care/wellness care as part of their clinical routine. Two studies, one “good” (17) and one “acceptable” (18), reported that about 50% of chiropractors used wellness, without further specification.

One “acceptable” study (7) looked at the proportion of patients in the general population who consulted chiropractors for prevention of MSK disorders and found that to be around 10%. One “acceptable” study of pediatric patients found similar results, while a “good” study of a pediatric population in Norway only showed 1% consulting. When patients were asked, in 3 “good” studies (20-22) and 3 “acceptable” studies (7, 19, 23), about their reasons for visiting a chiropractor, the prevalence of patients reporting primarily consulting for wellness and/or preventive care ranged from 2% in pediatric patients to 21% in adult patients.

Clinical Application & Conclusions:

The number of patients who report consulting a chiropractor for PP was much smaller than the number of chiropractors who report offering PP, which was much smaller than the number of chiropractors reporting a positive opinion of the various types of PP. A majority of chiropractors reported positive opinions and attitudes toward both public health activities and wellness. The authors found it surprising that so few patients seemed to see chiropractors as having something to offer in the area of PP. The reasons for this are unclear. Is there a perception among patients that chiropractors are equipped only to treat their back pain, do they perceive PP offerings as irrelevant or useless, or do they simply lack information on what chiropractors can offer in this area? Further research is needed to clarify these issues.

It is important to note that, although PP was rarely stated as the reason for consulting a chiropractor, PP could have certainly been dealt with as part of the course of treatment.

More research efforts have been directed at wellness than MSK disorder prevention or public-health related disorders. If chiropractors wish to provide more PP in clinical practice, it would be helpful to conduct more research into PP with relation to MSK disorders and work toward educating the general population with regards to what chiropractors can offer them in this area.

Study Methods:

The authors searched PubMed, Embase, Index to Chiropractic Literature, and Google Scholar from January 2000 through February 15th, 2017 for peer-reviewed articles. Text and reference lists of relevant articles were also searched by hand. The first author selected articles based on their titles, then with the second author, independently screened the abstract and full texts using the inclusion and exclusion criteria below. One reviewed article had been co-authored by one the authors of this review, so a third person reviewed that article.

Inclusion Criteria:
  • Surveys on chiropractors and/or chiropractic patients
  • Information included on: PP in relation to information on chiropractors’ opinions of the use of PP, and/or the percentage of chiropractors who reported using PP, and/or the percentage of patients who consult for PP in chiropractic practice or in a chiropractic student clinic
  • Articles in English, French, Swedish, Danish, or Norwegian
Exclusion Criteria:
  • Articles reporting on the topics described above, but on treatment not usually given by chiropractors
  • Articles on improvement of sport performance
  • In cases where several publications existed from the same study, the most relevant or complete publication in relation to this study’s objective was used
Information from the selected studies was reviewed for quality and results. A percentage score was given to each article regarding various quality aspects to rank the quality of the articles. Points for quality were given for the following aspects:
  • Target population was well defined
  • Study sample was described at least for age, sex, geographical distribution, or professional background
  • Sampling method, with random or consecutive samples awarded one point and convenience samples given 0 points
  • Response rate, or enough information to allow the response rate to be calculated, was provided. In addition, response rates of 10% or less were considered unacceptable, resulting in 0 points
  • In cases where the response rate was < 80%, response/non-response analysis was awarded a point
Points for validity of results were given for the following:
  • A clear definition or explanation of PP included
  • Relevant questions or questionnaires available for the reader
  • An attempt to assure the quality of the survey instrument
  • Opinions reported were anonymous and/or the confidentiality of the chiropractor was respected
  • The reason for consulting was reported by the chiropractor via actuarial reporting, but not approximate reporting
  • The reason for consulting was reported by the patients anonymously or if it was stated that the patients’ confidentiality was respected
Articles with a final score of 80% or higher were classified as good, articles scoring between 60 and 79% were classified as acceptable, and articles scoring < 60% were classified as unacceptable and discarded. Results from “good” studies were considered before those of “acceptable” studies.

Study Strengths / Weaknesses:

  • The AMSTAR checklist for methodological quality of systematic review was used in all areas except assessment of publication bias and assessment of conflict of interest.
  • Search strategies were developed in conjunction with a health science research librarian.
  • The systematic approach applied in this review helps to limit (although, does not completely remove) subjectivism in data analysis and interpretation.
  • The authors report that their requirements for inclusion of articles in the review was lenient. This may have led to the inclusion of poor quality articles.
  • Most studies failed to provide specific definitions of PP, making it difficult to properly classify the study data.
  • Response rates in studies were mainly low (below 80%), and few studies compared responders to non-responders.
  • As always, it is possible that the search strategy failed to retrieve some relevant articles.

Additional References:

  1. Global burden of disease study 2013 collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 386(9995): 743-800.
  2. World Health Organization. Health Promotion Glossary. 1998. Available from: http://www.who.int/healthpromotion/about/HPR%20Glossary%201998.pdf Accessed 15 Mar 2017.
  3. CCEA., C.o.C.E.A. Competency based standards f0r entry level chiropractors. 2009. Available from: http://www.ccea.com.au/index.php/accreditation/accreditation-documentation/. Accessed 15 Mar 2017.
  4. World Health Organization. WHO guidelines on basic training and safety in chiropractic. 2005. Available from: http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf. Accessed 15 Mar 2017.
  5. Hannon S. Objective physiologic changes and associated health benefits of chiropractic adjustments in asymptomatic subjects: a review of the literature. Journal of Vertebral Subluxation Research 2004: 1-9.
  6. Hawk C, Long CR, Perillo M, et al. A survey of US chiropractors on clinical preventive services. J Manip Physiol Ther 2004; 27(5): 287-298.
  7. Blum C, Globe G, Terre L, et al. Multinational survey of chiropractic patients: reasons for seeking care. J Can Chiropr Assoc 2008; 52(3): 175-184.
  8. Stuber K, Bruno P, Kristmanson K, et al. Dietary supplement recommendations by Saskatchewan chiropractors: results of an online survey. Chiro Man Ther 2013; 21(1): 11.
  9. McGregor M, Puhl AA, Reinhart C, et al. Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey. BMC Complement Altern med 2014; 14: 51.
  10. Leach RA, Cosman RE, Yates JM. Familiarity with and advocacy of Healthy People 2010 goals by Mississippi Chiropractic Association members. J Manip Physiol Ther 2011; 34(6): 394-406.
  11. Glithro S, Newell D, Burrows L, et al. Public health engagement: detection of suspicious skin lesions, screening and referral behaviour of UK based chiropractors. Chiro Man Ther 2015; 23(1): 5.
  12. Schneider MJ, Evans R, Haas M, et al. US chiropractors’ attitudes, skills and use of evidence-based practice: A cross-sectional national survey. Chiro Man Ther 2015; 23: 16.
  13. Fikar PE, Edlund KA, Newell D. Current preventative and health promotional care offered to patients by chiropractors in the United Kingdom: a survey. Chiro Man Ther 2015; 23: 10.
  14. Adams J, Lauche R, Peng W, et al. A workforce survey of Australian chiropractic: the profile and practice features of a nationally representative sample of 2,005 chiropractors. BMC Complement Altern Med 2017; 17: 14.
  15. Walker BH, Mattfeldt-Beman MK, Tomazic TJ, et al. Provision of nutrition counseling, referrals to registered dietitians, and sources of nutrition information among practicing chiropractors in the United States. J Am Diet Assoc 2000; 100(8): 928-933.
  16. McDonald WD, KF, Pfefer M. How chiropractors think and practice: the survey of North American chiropractors. Seminars in Integrative Medicine 2004; 2(3): 92-98.
  17. Malmqvist S, Leboeuf-Yde C. Chiropractors in Finland – a demographic survey. Chiropr Osteopat 2008; 16:9.
  18. Blanchette MA, Cassidy JD, Rivard M, et al. Chiropractors’ characteristics associated with their number of workers’ compensation patients. J Can Chiropr Assoc 2015; 59(3): 202-215.
  19. Hestbaek L, Jorgensen A, Hartvigsen J, A description of children and adolescents in Danish chiropractic practice: results from a nationwide survey. J Manip Physiol Ther 2009; 32(8): 607-615.
  20. Mootz RD, Cherkin DC, Odegard CE, et al. Characteristics of chiropractic practitioners, patients, and encounters in Massachusetts and Arizona. J Manip Physiol Ther 2005; 28(9): 645-653.
  21. French SD, Charity MJ, Forsdike K, et al. Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice. Med J Aust 2013; 199(10): 687-691.
  22. Brown BT, Bonello R, Fernandez-Caamano R, et al. Consumer characteristics and perceptions of chiropractic and chiropractic services in Australia: results from a cross-sectional survey. J Manip Physiol Ther 2014; 37(4): 219-229.
  23. Pohlman KA, Carroll L, Hartling L, et al. Attitudes and opinions of Doctors of Chiropractic specializing in pediatric care toward patient safety: a cross-sectional survey. J Manip Physiol Ther 2016; 39(7): 487-493.

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