Prevalence of Nonmusculoskeletal Complaints
in Chiropractic Practice: Report From a
Practice-based Research ProgramThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther 2001 (Mar); 24 (3): 157–169 ~ FULL TEXT
Cheryl Hawk, DC, PhD
Cynthia R. Long, PhD
Karen T. Boulanger
Palmer Center for Chiropractic Research,
Davenport, Iowa 52803, USA.
hawk_c@palmer.eduObjective: To identify patient and practice characteristics that might contribute to people's seeking chiropractic care for nonmusculoskeletal complaints.
Design: This was a cross-sectional study conducted through the methods of practice-based research.
Setting: Data were collected in 1998-1999 in chiropractic offices in the United States, Canada, and Australia; data were managed by a practice-based research office operating in a chiropractic research center.
Population: The subjects were new and established patients of all ages who visited the participating offices during a designated data collection week. Data Analysis: Multiple logistic regression was used to examine factors associated with patients' presenting for nonmusculoskeletal chief complaints. Pearson's2 test was used to examine associations among practice variables and the proportion of patients with nonmusculoskeletal chief complaints.
Results: A total of 7651 patients of 161 chiropractors in 110 practices in 32 states and 2 Canadian provinces participated; data from 2 Australian practices were included in the totals but not in the analysis. Nonmusculoskeletal complaints accounted for 10.3% of the chief complaints. The following characteristics made patients more likely to present with nonmusculoskeletal chief complaints: being less than 14 years of age (adjusted odds ratio [AOR], 6.9; 95% CI, 5.2-9.1); being female (AOR, 1.5; CI, 1.3-1.8); presenting in a small town/rural location (AOR, 1.9; CI, 1.3-2.7); reporting more than 1 complaint, especially nonmusculoskeletal complaints (AOR, 4.9; CI, 3.9-6.0); having received medical care for the chief complaint (AOR, 3.4; CI, 2.9-4.1); and having first received chiropractic care before 1960 (AOR, 1.7; CI, 1.1-2.4). Practices with the highest proportion of patients with nonmusculoskeletal chief complaints (>17%) were less likely to accept insurance and more likely to be in locations with populations greater than 100,000. They used the most common chiropractic adjustive techniques less frequently and used more nonadjustive procedures, especially diet/nutrition counseling, nutritional supplementation, herbal preparations, naturopathy, and homeopathy.
Conclusions: Drawing on practices with the patient and practice characteristics identified in this study to conduct outcomes studies on nonmusculoskeletal conditions is a possible direction for future research.
Key Indexing Terms: Chiropractic, Practice-based Research, Visceral Disorders
From the FULL TEXT Article:
INTRODUCTION
To build the evidence base of chiropractic, controlled clinical studies of its efficacy for patients with nonmusculoskeletal disorders are important. [1–3] As noted in 1997 by Chapman-Smith [1]:Well-designed randomized controlled trials have demonstrated the effectiveness of chiropractic manipulation in the treatment of musculoskeletal disorders . . . but there is no comparable evidence to support the chiropractic management of visceral disorders. We are at the point today where the value of chiropractic intervention in visceral cases is unproven—neither disproved nor proven . . . Relatively few patients consult a chiropractor or are referred for visceral disorders.
A recent well-designed study of the demographic and clinical characteristics of chiropractic patients in the United States and Canada indicated that fewer than 1% of chiropractic patients seek care for nonmusculoskeletal conditions. [4] Thus there is an apparently small pool of patients from which observations about chiropractic care for nonmusculoskeletal conditions can be made.
Designing controlled studies of nonmusculoskeletal disorders is difficult because we do not know which patients, disorders, and chiropractic techniques should be targeted. [5] If these factors are not identified, confounding variables are likely to complicate the study; worse, an inappropriate patient population or treatment protocol could be chosen.
The purpose of this study was to identify patient and practice characteristics that might contribute to people’s seeking chiropractic care for nonmusculoskeletal complaints. This will provide information that might be helpful in identifying future sources of more detailed information about chiropractic use by patients with nonmusculoskeletal complaints. Furthermore, identification of such characteristics could be useful to chiropractic educators and practitioners who are interested in the application of chiropractic care to a broader range of health conditions.
DISCUSSION
Before the implications of this study are discussed, it is important to stipulate the limitations of any PBR study that should be kept in mind when results are being considered. PBR is conducted among volunteer practices and their consenting patients; data collected from these sources might or might not be generalizable to the general population. [7–11] For example, because of the nonrepresentative distribution of participants with respect to chiropractic college, we were not able to assess whether this factor influenced practice characteristics. Another limitation of PBR is that data are collected in distant participating offices, and it is difficult to ensure that data are complete—in terms of including all eligible patients and answering all questions—and accurate—in terms of assessing patient and doctor self-reports. Our quality assurance procedures indicated that 8 of the 11 practices assessed included over 75% of their patients in the study; however, 3 practices included less than 60% of their patients, though these offices’ underreporting appeared not to be systematic. Thus it is important to keep in mind that our results reflect only what we found in the participating practices among patients who were included in the study. For example, Canadians represented in this study were much less likely to seek care for nonmusculoskeletal conditions than were US patients; this finding might be limited to our Canadian practice sample, which represented only 2 of the country’s provinces. However, we feel that the observations that we were able to make about these practices and patients have important implications for chiropractic education and practice, as we will discuss next.
First, it is important to note that even though we actively recruited practices that saw a higher-than-average proportion of patients with nonmusculoskeletal complaints, such complaints still account for a relatively small proportion of the chief complaints — 10.3% overall, individual conditions contributing less than 2% each. However, it is clear that we recruited a number of practitioners who saw far more patients with nonmusculoskeletal chief complaints than is common in most chiropractic practices, so we had an adequate sample size from which to make comparisons.
The purpose of all comparisons made in this study was to identify characteristics of patients seeking chiropractic care for nonmusculoskeletal conditions and of practitioners associated with such patients. We thus investigated 2 main types of characteristics: those of patients and those of practices/practitioners.
The patient demographic characteristics associated with seeking care for a nonmusculoskeletal complaint were sex and age. In general, female patients were more likely to present with a nonmusculoskeletal condition; it is possible that women in general are more open to seeking complementary care. However, patients aged 14 years and under, particularly if they were male, were far more likely than any other age group to report a nonmusculoskeletal chief complaint (AOR, 8.6 for females and 9.5 for males). Although the data are limited by the unavailability of specific ages within this group, from the available data on chief complaints it appears that the nonmusculoskeletal conditions represented in this group are among those that are medically managed through use of medications which parents may find objectionable (attention deficit disorder/attention deficit disorder with hyperactivity, asthma, ear infection, sinus problems) or for which medical treatment is not generally offered (upper respiratory infections, enuresis).
It has been hypothesized among DCs that the result of educating patients about the value of chiropractic for problems other than musculoskeletal pain will be that patients who originally seek care for musculoskeletal complaints will later seek care for nonmusculoskeletal complaints. In addition, it has been hypothesized that a patient with a musculoskeletal chief complaint will often have additional nonmusculoskeletal complaints for which he or she also seeks care. We were able to address these hypotheses in a limited fashion in this cross-sectional study by eliciting self-reporting of 3 complaints and information on duration of the complaints and the length of time that patients had had any experience with chiropractic. It appears from our results that:
Patients reporting additional complaints, particularly if they were nonmusculoskeletal, were more likely to present with a nonmusculoskeletal chief complaint.
Duration of the chief complaint was not associated with seeking care for a nonmusculoskeletal complaint; however, patients who did not specify a duration were more likely to have a nonmusculoskeletal complaint—perhaps because many such complaints (eg, fatigue) have an indeterminate onset.
After age was adjusted for, length of time since the first chiropractic experience was significant only for patients who first sought chiropractic care before 1960; this may indicate either characteristics of chiropractic practice in that era or attitudes or other characteristics of those patients.
Our results showed that patients receiving care from an MD for their complaint were more likely to have a nonmusculoskeletal chief complaint and that those receiving only chiropractic care were less likely to have a nonmusculoskeletal chief complaint. This finding supports what has been found in other studies13: that people often seek complementary health care, such as chiropractic, in addition to medical care. It does not support the hypothesis that DCs serve as primary care providers for conditions other than musculoskeletal ones.
Several practice and practitioner characteristics varied considerably in relation to the prevalence of patients seeking care for nonmusculoskeletal conditions. Although we were able to assess patient volume only in solo practices, there was still an indication that lower volume might be associated with a higher prevalence of nonmusculoskeletal complaints; this would bear further study of a more controlled nature. Practices that accept insurance, including Medicare and Medicaid as well as private insurance, clearly had fewer patients reporting nonmusculoskeletal chief complaints.
As regards services offered to patients, there were pronounced differences between practices with a high proportion of patients reporting nonmusculoskeletal complaints and those with a low proportion of such patients. First, HI-non-MS practices used more uncommon chiropractic adjustive techniques. The most commonly used techniques in the United States are Diversified, Gonstead, Flexion-Distraction, and Activator [14]; these were also the techniques most commonly noted in this study, with the exception of Flexion-Distraction, which was not represented at all. The 3 most commonly used techniques were used less in HI-non-MS practices. Second, HI-non-MS practices used considerably more nonadjustive procedures, especially those related to nutrition, herbs, and supplements, whereas HI-MS practices used fewer nonadjustive procedures, with two notable exceptions: physical modalities and exercise.
CONCLUSION
From these results we infer that DCs who provide a broader scope of chiropractic practice—one that includes (in addition to chiropractic adjustments) nutrition and other complementary and alternative procedures, such as homeopathy, acupressure, acupuncture, and naturopathy—attract patients who have nonmusculoskeletal health problems, frequently ones with complex or poorly understood etiologies that are not completely managed exclusively through use of medical care. Drawing on the pool of DCs with this orientation to conduct outcomes studies is a possible direction for future research investigating the impact of complementary and alternative therapies on such conditions in a real-life setting.
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