J Manipulative Physiol Ther. 2017 (Oct 24) [Epub] ~ FULL TEXT
Mette Hobaek Siegenthaler, DC, MSc
Swiss Academy for Chiropractic,
OBJECTIVES: The purpose of this study was to investigate practice characteristics of chiropractors who treat pediatric patients in Swiss chiropractic clinics.
METHODS: An online survey questionnaire was created and tested for face and content validity. Participation by Swiss chiropractors was voluntary and anonymous and completed November to December 2015. The data were analyzed using SPSS. The analysis consisted of descriptive statistics.
RESULTS: The sample consisted of 144 chiropractors, which represented a 53% response rate, and 98% of the responding practitioners treated patients younger than age 18. The proportion of pediatric patients treated was 8.7%. The most common pediatric age groups were schoolchildren and adolescents, with infants younger than 6 months being the third most common. Musculoskeletal complaints were the most common conditions treated in all age groups. In children younger than 2 years old, nonmusculoskeletal conditions were well represented. Prophylactic examination was common among children 6 years and younger. A total of 61% of responding chiropractors received direct referrals from medical doctors and 56% received direct referrals from pediatricians. The most common age groups for referrals from pediatricians were schoolchildren and adolescents. Only 15% of the chiropractors wrote reports about their pediatric patients to their pediatrician often or regularly; 90% of the responding chiropractors stated they rarely or never refer to a pediatric specialist, and 80% of the chiropractors have never or have rarely been invited to attend medical congresses or to teach the pediatric health care community about chiropractic care for children.
CONCLUSION: The majority of chiropractors in Switzerland treat pediatric patients, most commonly schoolchildren and adolescents for musculoskeletal disorders.
KEYWORDS: Chiropractic; Patients; Pediatrics; Practice; Questionnaire
From the FULL TEXT Article:
Surveys on chiropractic pediatric care have been undertaken in some countries to map standards and needs in the profession, with most originating from North America and Europe. [1–6] In Switzerland, however, no such survey on chiropractic pediatrics has been previously conducted. In 2009, a Swiss job analysis survey of chiropractors was conducted to identify specific characteristics of chiropractic practice to ensure that relevant key competencies in practice were covered in the undergraduate and postgraduate chiropractic program that started at the University of Zürich in 2008.  A key finding of this Swiss survey was that 91% of responding chiropractic practitioners reported treating patients between the ages of 6 and 17, and 78% reported treating children younger than 5 years of age.
Furthermore, 22% of Swiss chiropractors reported receiving direct referrals from pediatricians
“sometimes” (1–3 patients per month),
“often” (1–2 per week), or
“routinely” (>2 per week).
These numbers are higher than those reported in surveys conducted in other countries,  and they are thus of great interest to the profession and suggest that a further investigation into pediatric patients in Swiss chiropractic clinics is needed.
Switzerland is in a unique position within the international chiropractic profession because it is the only country where chiropractic is one of the 5 government-recognized medical professions (medicine, dentistry, veterinary medicine, pharmacology, and chiropractic). Furthermore, Switzerland has the first chiropractic program that is part of a faculty of medicine.  With the findings from the Swiss job analysis together with the unique status of Swiss chiropractors, the chiropractic profession in Switzerland could try to take a more active role in monitoring musculoskeletal development in children and take a more active part in pediatric research.
To do so, a detailed investigation into the pediatric patients in Swiss chiropractic clinics was needed. The survey of the pediatric patients in Swiss chiropractic clinics that is presented in this paper is based on that of Humphreys et al,  and its rationale was to consider pediatric patients in Swiss chiropractic clinics in greater detail. Such investigations help to map potential improvements to chiropractic undergraduate, postgraduate, and continuing education; to identify possible implications for future chiropractic research; to investigate the professional relationship between chiropractors and other pediatric health care providers; and to better understand interdisciplinary relations. Therefore, the purpose of this study was to investigate practice characteristics of chiropractors who treat pediatric patients in Swiss chiropractic clinics.
This description of chiropractic practice contributes to a better understanding of current Swiss chiropractic practices, the professional relationship between chiropractors and other pediatric health care providers, and interdisciplinary relations. The proportion of pediatric patients in Switzerland in this study was smaller than that of the adult population and similar to the European average.  However, the proportion of pediatric patients varied between chiropractors and some chiropractors see far more pediatric patients than others. Very few chiropractors stated they do not treat children 17 years and younger, indicating that the treatment of pediatric patients is widespread among Swiss chiropractors.
The most common age group attending the chiropractic clinics was the adolescent age group, with schoolchildren being the second most common. This is different from Scandinavian countries, where the major proportion of pediatric patients is 1 year old and younger, [2, 3] but it is similar to the findings in Europe overall, where the adolescent group is the most common age group attending chiropractic clinics. 
The most common conditions treated in the adolescent age group were spinal musculoskeletal disorders. Very few chiropractors stated that they treated nonmusculoskeletal disorders in this group, such as “asthma,” “menstruation,” or “concentration/hyperactivity.” The reason for this might lie in the fact that the effectiveness of chiropractic treatment of nonmusculoskeletal disorders is poorly researched.  Furthermore, in this present survey, the musculoskeletal complaints in the 6– to 12–year-old group were also mainly of a spinal nature, but this age group less commonly attended chiropractic clinics than the 13– to 17–year-old group, which supports the growing evidence that spinal pain starts early and the cumulative incidence increases to reach adult levels by the age of 18. 
In the 0– to 6–month-old group, “infantile torticollis/asymmetry” was the most common condition treated, with “excessive crying/infantile colic” being the second most common. This differs from results seen in Scandinavian surveys where “excessive crying/infantile colic” accounted for more than half of the reasons for attendance in these youngest patients. [2, 3] The reason for this difference might lie in a long history of treating “infantile colic/excessive crying” in Scandinavian countries,  and thus the chiropractic treatment of these conditions might be more appreciated in the medical and general population of that country, whereas in Switzerland it is seemingly underaccessed.
Corresponding with the natural development of musculoskeletal disorders in childhood, musculoskeletal complaints in the form of overuse and trauma occur less often in preschool-aged children than in older children.  This could explain why the 7– to 23–month-old and 2– to 5–year-old groups were the least common age groups seen in Swiss chiropractic clinics. Supporting this, in the 7– to 23–month-old group, nonmusculoskeletal disorders, such as “ear pain/otitis media,” “disturbed sleep,” and “crying/irritability,” were conditions treated almost as often by the chiropractors as musculoskeletal disorders. In contrast, 2– to 5–year-old children were mainly treated for musculoskeletal complaints of the spine and posture problems. There is no clear explanation for this, but it is possible that posture problems and musculoskeletal problems were findings addressed during a “prophylactic examination,” which was widespread among Swiss chiropractors in this age group.
The reason why “prophylactic examination” was often addressed might partly lie in the annual spinal screening day in Switzerland, when schoolchildren are invited for a free spinal screening in a chiropractic clinic. However, because “prophylactic examination” was often addressed in infants, presumably the general public trusts in the chiropractic profession’s judgment of children’s health and thus brings them in for a “checkup.” In the United States, “wellness care” is common practice in chiropractic offices that specialize in children,  but it is unclear if “wellness care” means a series of prophylactic treatment sessions over time or if this refers to one prophylactic examination/screening examination, similar to Switzerland.
To measure the integration of the chiropractic profession in the pediatric health community, the number of referrals to and from chiropractic clinics was included in the questionnaire. Although the majority of the chiropractors in Switzerland stated that their pediatric patients were mainly referred by “parents/siblings or other family members” and “through word of mouth/nonfamily patients referrals,” a majority of the Swiss chiropractors stated they also receive referrals from general medical practitioners and pediatricians in private practice. Furthermore, the most common age groups referred to the chiropractors from pediatricians in private practice were the 6– to 12– and 13– to 17–year-old groups, similar to the most common age group seen in Swiss chiropractic clinics.
On the other hand, when asking the chiropractors how often they referred pediatric patients to other pediatric medical specialists, the majority said they would “rarely” (<1/mo) do so. Here there seemed to be a difference from the adult patient population, and, in their survey, Humphreys et al  found that a majority of Swiss chiropractors referred patients to other medical specialists “sometimes” (1–3/mo), “often” (1–2/wk), or “routinely” (>2/wk). The explanation for this difference might be that many adult patients in Switzerland do not have a family doctor, but the majority of pediatric patients do. Thus, further referrals might take place through the pediatrician’s office, and, moreover, referrals to other specialists are, presumably, less common in the pediatric than in the adult population.
Some of the responding chiropractic participants stated that they would receive pediatric referrals from other chiropractors, indicating that some chiropractors are more specialized in pediatrics than others and confirming a positive interdisciplinary relationship among chiropractors. Few of the chiropractors stated that they wrote reports about their pediatric patients to the child’s pediatrician “routinely” (>2/wk) or “often” (1–2/wk). It is unclear why the chiropractors choose not to write reports to the pediatricians more often, but the reason might lie in insecurity about framing pediatric reports. Moreover, very few of the chiropractors stated that they had “been invited to teach or inform about chiropractic at pediatric health care communities” “sometimes” (every few years), “often” (once a year), or “routinely” (>1 time a year), and only a minority of the chiropractors stated that they had “been invited to participate in pediatric medical congresses, pediatric hospital meetings, or panel discussions representing chiropractic and its opportunities in the field of pediatrics” “sometimes” (every few years), “often” (once a year), or “routinely” (>1 time a year). This displays a lack of communication between chiropractors and pediatric medical doctors, and it is definitely a gap in integration into the pediatric health care community.
A popular way of gaining knowledge in chiropractic pediatrics, especially in North America, is to attend postgraduate diplomate programs.  Humphreys et al  reported that diplomate programs in Switzerland are not that popular, and similarly this study determined that diplomate courses and postgraduate studies in chiropractic pediatrics are not commonly undertaken. The reason for this might be the length of the mandatory, 2+ year postgraduate education program for chiropractors in Switzerland compared with other countries where at most a 1–year postgraduate program is offered.  Furthermore, in this survey the Swiss chiropractors stated that they acquired most of their continuing education in pediatrics through “reading journals” and attending “chiropractic/manual medicine/osteopathic courses.” One reason for this might be that Swiss chiropractors are able to obtain up to 30 of their 80 required continuing education credits per year from reflective self-study.
The response rate to the questionnaire distributed in this study was acceptable, although lower than that obtained in the study by Humphreys et al.  One possible reason may be that some chiropractors chose not to complete this survey because they did not treat children and therefore did not think it was relevant to them. The length of the survey was similar, but the survey of Humphreys et al  was not specifically aimed at a chiropractic field. Furthermore, in the study of Humphreys et al,  all chiropractors were awarded 5 continuing education credits for submitting a completed survey, a factor that may well have helped to achieve such a good response rate.
Comparing the demographic data in the 2 surveys, similarities as well as differences were revealed. In both studies, the most common period to have been in practice was between 5 and 15 years, followed by 16 to 25 years. Furthermore, the male/female ratio in this study was 62% to 38%, whereas in the study by Humphreys et al  it was 73% to 27%, which is closer to the actual sex ratio for the whole Swiss Association: 71% male to 29% female (information from the Swiss Chiropractic Association). There is no clear marker that says whether a sex ratio is representative or not in questionnaire surveys, but in this survey some male chiropractors might have chosen not to answer the questionnaire because they do not treat children. The ratio of chiropractors in the German-, French-, and Italian-speaking parts of Switzerland in this study was 66%, 30%, and 4%, respectively, which is close to the actual ratio: 69% German speaking, 27% French speaking, and 4% Italian speaking (information from the Swiss Chiropractic Association, www.chirosuisse.ch/de).
As with any questionnaire survey, inherent bias and bias stemming from self-reported information are limitations, although the questions were designed to minimize the risk of such bias. No attempt was made to verify the answers provided because this would violate the anonymity of the participants. The survey instruments used was a quite lengthy questionnaire, which could have negatively influenced response rates. Furthermore, it is possible that the response rate was lowered as a result of some chiropractors choosing not to complete the survey because they did not treat children. In addition, some male chiropractors might have chosen not to answer the questionnaire because they do not treat children, explaining why the female ratio in this study was higher than the actual female ratio for the whole Swiss Chiropractic Association. No attempt was made to determine the reasons behind the fact that 47% of Swiss chiropractors did not return the survey. The findings of this study are limited to the population surveyed.
Implications for Research and Education
Currently there is limited evidence on the chiropractic treatment of children and adolescents. [12, 13] Because schoolchildren and adolescents seek chiropractic care with musculoskeletal complaints, the Swiss chiropractic profession could use this opportunity to take a more active role in providing evidence about musculoskeletal health in those age groups, including etiology, prevalence, diagnostics, treatment, and prevention. Furthermore, in the youngest patients, the 0– to 6–month-old group, the chiropractic care of infantile torticollis is common, but the available evidence regarding chiropractic treatment of musculoskeletal disorders in infants, such as infantile torticollis, is sparse, and thus the chiropractic profession in Switzerland should be motivated to provide evidence to support the value of the chiropractic treatment of musculoskeletal disorders in infants.
The undergraduate and postgraduate chiropractic education system in Switzerland offers mandatory pediatric lectures. Because so many schoolchildren and adolescents seek chiropractic care with musculoskeletal complaints, the diagnostics, the differential diagnostics, and the treatment of musculoskeletal complaints in this age group deserve greater priority in the curriculum, as well as in the continuing education. Furthermore, the reason why Swiss chiropractors do not engage in report writing and in referrals to medical doctors might lie in insecurity about framing pediatric reports, and hence report writing should also be a further inclusion in the undergraduate and postgraduate curriculum.
Implications for Interdisciplinary Relations
Additional report writing training and skills may help Swiss chiropractors with their communications, so they can become more integrated in the pediatric health care community. The chiropractic profession could try to take a more active role in monitoring and treating musculoskeletal disorders in the pediatric population. Swiss chiropractors should aim toward better integration in the medical community through greater involvement in interdisciplinary medical congresses, pediatric hospital meetings, and panel discussions on musculoskeletal disorders in children.
This survey of the pediatric patients in Swiss chiropractic clinics reflects current chiropractic practice in Switzerland. The 2 largest groups of pediatric chiropractic patients in Switzerland were schoolchildren and youths presenting as a result of spinal musculoskeletal complaints. The third most common age group was the 0– to 6–month-old group, which attended because of “infantile torticollis/asymmetry.” This study provides information that will help focus on opportunities that will allow Swiss chiropractors to improve education, research, and interprofessional relations.
The findings in this study will help guide undergraduate, postgraduate, and continuing education in chiropractic pediatrics in Switzerland, implicate for interdisciplinary relations, as well as help to guide future research projects
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