J Manipulative Physiol Ther. 2005 (Nov); 28 (9): 645653 ~ FULL TEXT
Robert D. Mootz, DC, Daniel C. Cherkin, PhD, Carson E. Odegard, DC, MPH,
David M. Eisenberg, MD, James P. Barassi, DC, Richard A. Deyo, MD, MPH
State of Washington,
Department of Labor and Industries,
Olympia 98504-4321, USA.
OBJECTIVE: To describe chiropractic care using data collected at the time of each patient visit.
METHODS: Random samples of chiropractors licensed in Arizona and Massachusetts were recruited to participate in interviews about their training, demographics, and practice characteristics. Interviewees were then recruited to record information about patient condition, evaluation, care, and visit disposition on 20 consecutive patient visits.
RESULTS: Data for 2,550 chiropractic patient visits were recorded. Care for low back, head and neck pain accounted for almost three quarters of visits. Extremity conditions and wellness care accounted for approximately half of the remaining visits. Spinal and soft tissue examinations were the most frequently reported diagnostic procedures (80% and 56% of visits, respectively), and high-velocity spinal manipulation techniques were the most frequently reported therapeutic procedures (almost 85% of visits). Rehabilitation exercises, thermal modalities, electric stimulation, and counseling/education/self-care were each performed during approximately 25% of visits. Approximately 85% of patients seen were self-referred, whereas only approximately 5% came from medical physicians. Approximately 35% of visits had an expected source of payment directly from the patient. Approximately 80% of visits ended with a plan for the patient to return at a specified time.
CONCLUSION: These findings are consistent with the findings of previous studies and confirm that chiropractors use conventional patient assessment approaches with specific attention to spinal and musculoskeletal procedures, infrequently incorporating interventions commonly associated with other complimentary and alternative care providers. These findings illustrate that diagnostic assessment and follow-up are integral to chiropractic clinical encounters and offer a baseline for best practices development. The data also offer insight into chiropractic use and may be of interest to chiropractic leaders and education planners for professional development purposes.
From the FULL TEXT Article:
The number of chiropractors in the United States has grown steadily in recent years.  The use of chiropractic services has also been increasing although it appears to have plateaued. [2, 3] With more than 60,000 practitioners in North America, chiropractic is now one of the largest health professions and is expected to approach 100,000 by 2010.  The increasing contributions of chiropractors in health care has generated greater interest in understanding the characteristics of chiropractic practice patterns and treatments. Four systematic approaches have been used to gather information about chiropractic practice: chart abstraction, patient recall surveys, practitioner recall surveys, and reviews of administrative/utilization databases. [1, 57] All of these approaches suffer from the limitations of either patient or provider recall, or rely on data collected through retrospective review of records not designed with research in mind.
The current study takes a different approach to describing the practices of chiropractors in the USA. It is patterned after the National Ambulatory Medical Care Survey (NAMCS) that collects practice encounter characteristics close to the time of each patient encounter.  This approach allows for standardized collection of visit data immediately after individual patient encounters, minimizes problems of long-term provider recall, limits the artifacts of chart documentation focused on insurance reimbursement requirements, and avoids the pitfalls of retrospective administrative data analysis.
In contrast to previous descriptions of chiropractors and their practices, this study collected standardized data immediately after individual patient encounters. This minimized problems of long-term provider recall, limited the artifacts of chart documentation focused on insurance reimbursement requirements, and avoided the pitfalls of retrospective administrative data analysis. In addition, the response rates in our study were higher than those of the two national practitioner-recall surveys, [1, 14] and our respondents reported more years in practice. Our higher response rates may reflect our sampling strategy that involved community opinion leaders and telephone follow-up to encourage participation. In addition, our survey was much briefer than that used in the NBCE survey. The main limitation of our study is that it was conducted in only two states.
Although data from Massachusetts and Arizona are generally similar, some differences were noted. Arizona providers reported more patient visits per week, less reimbursement from private insurance (including managed care) and more frequent use of several components of the clinical evaluation and plain film radiography. Massachusetts chiropractors used electrical stimulation and thermal modalities more frequently. Although the total proportion of DCs practicing with medical doctors is small in both states, more Arizona practitioners reported practicing in offices with MDs than did those in Massachusetts. Several of these differences likely reflect regional differences in the culture of health care delivery settings, whereas others may relate to where providers received their training.
For the most part, where data allow meaningful comparisons, our findings are consistent with data from previous surveys. The biggest difference between the findings of our study and those of prior surveys is the higher proportion of low back conditions and lower proportion of head and face pain conditions documented in the RAND chart extraction study.  Although variation in patients' conditions cannot be ruled out, it is also possible that condition-specific differences in insurance coverage documentation requirements are responsible. Coverage for chiropractic services provided for nonlow back pain conditions can have increased administrative burden and reimbursement requirements. Our study captured real-time reasons for visit without regard to making an insurance diagnosis, whereas the RAND study relied on chart documentation to determine reason for visit. Explanation of these differences in the reasons patients visit warrants further investigation. Aside from this finding and a few potentially regional variations in specific diagnostic and therapeutic preferences (possibly due to scope of practice regulations and/or training), the national character of chiropractic patients and practices nationally is probably fairly accurately reflected in our findings.
Our study was not specifically designed to evaluate the extent to which chiropractors provide a broad range of complementary or alternative therapies. However, we found that although chiropractors often provided injury prevention counseling and various kinds of therapeutic and conditioning exercises, they only rarely reported use of therapeutic modalities traditionally included in alternative medicine practices (eg, acupuncture and nutritional supplements). Although our practice inventory instrument included sections for nutritional supplementation, diet counseling, health-risk evaluation, homeopathic remedies, and tobacco use, fewer than 2% of visits in Massachusetts and 4% of visits in Arizona included any of these components. A survey by Hawk et al  of a random sample of chiropractors in the USA found that DC's opinions were equally divided regarding whether or not chiropractic should be defined as a complementary health profession, but the vast majority believed it should be considered as a complete health care system as opposed to a therapeutic modality.
In fact, the data in this report paint a picture of regularly applied conventional patient assessment approaches with specific attention to spinal and musculoskeletal procedures. Standard patient management activities, including diagnostic assessment and follow-up, are integral to chiropractic clinical encounters. Therapeutic interventions most frequently involve standard high-velocity chiropractic spinal adjusting techniques along with a substantial proportion of soft tissue and/or physiotherapeutic techniques.
Chiropractic leaders, trade groups, and academics should find these results of interest as there continues to be internal debate about the role chiropractors play, or should play, in drugless primary care and triage roles.  Recent actuarial reports suggest that increased use of chiropractic is associated with lower utilization or substitution for other health care services. [16, 17] Identifying the most appropriate roles for chiropractors within conventional delivery settings and rational approaches to the coverage for chiropractic services should be priorities for further research.
Health services researchers in chiropractic should find chiropractors' choices of specific therapeutic interventions and techniques helpful for understanding the way chiropractic is actually practiced. In addition, current efforts to promote wider adoption of evidence-based best practices should find our data helpful to identify opportunities for quality improvement. For example, evidence suggests that combinations of manipulation and active rehabilitation interventions may optimize patient outcomes ; however, such combinations appear not to be used in the majority of encounters, at least in Massachusetts and Arizona. Finally, health care policy makers, regulators, and purchasers should be reassured by our findings that chiropractors, like other health professionals, commonly conduct systematic patient evaluations (eg, assessment of chief complaint, history, and physical examination) in addition to providing therapy.
The information from this study is consistent with the findings of previous studies and confirms that chiropractors use conventional patient assessment approaches with specific attention to spinal and musculoskeletal procedures, infrequently incorporating interventions commonly associated with other complimentary and alternative care providers. The findings illustrate that diagnostic assessment and follow-up are integral to chiropractic clinical encounters and offer a baseline for best practices development. The data also offer insight into chiropractic use and may be of interest to chiropractic leaders and education planners for professional development purposes.
A unique feature of this study was that it collected standardized data
immediately after individual patient encounters.
This study documented a higher proportion of head and face complaints
and a lower proportion of low back complaints than the comprehensive
RAND chart extraction study.
Although chiropractors often provided injury prevention counseling and
various kinds of therapeutic and conditioning exercises, they only rarely
reported use of therapeutic modalities traditionally included in
alternative medicine practices (eg, acupuncture and
Standard patient management activities, including diagnostic assessment
and follow-up, are integral to chiropractic clinical encounters.
Therapeutic interventions most frequently involve standard high-velocity
chiropractic spinal adjusting techniques along with a substantial
proportion of soft tissue and/or physiotherapeutic techniques.
Christensen MG, Kerkhoff D, Kollasch MW.
Job Analysis of Chiropractic 2000
Greeley (CO): National Board of Chiropractic Examiners, 2000.
Eisenberg, DM, Davis, RB, Ettner, SL, Appel, S, Wilkey, S, Van Rompay, M et al.
Trends in Alternative Medicine Use in the
United States, from 1990 to 1997:
Results of a Follow-up National Survey
JAMA 1998 (Nov 11); 280 (18): 15691575
Tindle, HA, Davis, RB, Phillips, RS, and Eisenberg, DM.
Trends in use of complementary and alternative medicine by US adults: 1997-2002.
Altern Ther Health Med. 2005; 11: 4249
Cooper, RA and Stoflet, SJ.
Trends in the education and practice of alternative medicine clinicians.
Health Aff. 1996; 15: 226238
Use of chiropractic services from 1985 through 1991 in the United States and Canada.
Am J Publ Health. 1998; 88: 771776
Shekelle PG, Coulter I, Hurwitz EL, Genovese B, Adams AH.
Congruence Between Decisions To Initiate Chiropractic Spinal Manipulation
for Low Back Pain and Appropriateness Criteria in North America
Annals of Internal Medicine 1998 (Jul 1); 129 (1): 917
Benchmarking the clinical and financial characteristics of chiropractic offices.
Top Clin Chiropr. 2001; 8: 1319
Schneider, D, Appleton, L, and McLemore, T.
National Center for Health Statistics: a reason for visit classification for ambulatory care.
([DHEW Pub No (PHS) 79-1352])
in: Vital and health statistics, series 2, no. 8.
US Public Heath Service, Washington (DC); 1979
Cherkin, DC, Deyo, RA, Sherman, KJ, Hart, LG, Street, JH, Hrbek, A et al.
Characteristics of licensed acupuncturists, chiropractors, massage therapists and naturopathic physicians.
J Am Board Fam Pract. 2002; 15: 378390
Cherkin, DC, Deyo, RA, Sherman, KJ, Hart, LG, Street, JH, Hrbek, A et al.
Characteristics of Visits to Licensed Acupuncturists, Chiropractors,
Massage Therapists, and Naturopathic Physicians
J Am Board Fam Pract 2002; 15 (6):463-480
Cherkin, DC and Mootz, RD.
Chiropractic in the United States: training, practice, and research
Agency for Health Care Policy and Research, Rockville (Md); 1997: 3338
Coulter, ID, Hurwitz, EL, Adams, AL, Genovese, BJ, Hays, R, and Shekelle, PG.
Patients Using Chiropractors in North America:
Who Are They, and Why Are They in Chiropractic Care?
SPINE (Phila Pa 1976) 2002; 27 (3) Feb 1: 291298
in: M Christensen, D Delle Morgan (Eds.)
Job analysis of chiropractic: a project report, survey analysis and summary of the practice of chiropractic within the United States.
National Board of Chiropractic Examiners, Greeley (Colo); 1993: 4779
Summary of the ACA professional survey on chiropractic practice.
J Am Chiropr Assoc. 2001; 38: 2730
Hawk, C, Byrd, L, Jansen, RD, and Long, CR.
Use of complementary health care practices by chiropractors in the United States: a survey.
Altern Ther. 1999; 5: 5662
Sarnat, RL and Winterstein, J.
Clinical and Cost Outcomes of an Integrative Medicine IPA
J Manipulative Physiol Ther 2004 (Jun) ; 27 (5): 336347
Legorreta, AP, Metz, RD, Nelson, CF, Ray, S, Chernicoff, HO, and Dinubile, NA.
Comparative Analysis of Individuals
With and Without Chiropractic Coverage:
Patient Characteristics, Utilization, and Costs
Arch Intern Med 2004 (Oct 11); 164 (18): 19851892
Bronfort, G, Haas, M, and Evans, R.
The clinical effectiveness of spinal manipulation for musculoskeletal conditions.
in: S Haldeman (Ed.) Principles and practice of chiropractic. 3rd ed.
McGraw Hill, New York; 2004: 147166
Return to the LOW BACK PAIN Section