Response rate

In Sweden, 359 questionnaires with complete answers were returned. In addition, 12 questionnaires were returned with incomplete answers and were therefore excluded from the study. Another two letters were returned unopened due to retirement. Thus, the response rate of completed questionnaires was 44.8%. In Norway, 387 questionnaires were returned, of which 376 were complete. Ten questionnaires were returned due to incorrect addresses and 1 was returned due to retirement, rendering a response rate of 45.3%.

Demographic data

The sample of Swedish GPs was slightly older than the Norwegian sample. Fifty-nine per cent of the Swedish GPs were aged 51 years or older whereas the corresponding number in Norway in this age group was 43%. Only one GP in Sweden was aged between 20 and 30, whereas in Norway, 19 GP’s fitted this category. Of the Swedish GPs, 58% were male and in the Norwegian sample 64% were male.

Opinions and experiences of chiropractic

The questionnaire started with the general question; “How would you describe your knowledge of chiropractic?

Seven per cent of the Swedish GPs felt that they had good knowledge of chiropractic and 53% felt that they had poor knowledge. The remaining 40% claimed to know something about chiropractic. In Norway, 22% of the GPs felt that they had good knowledge, 12% said that they had poor knowledge and 66% claimed to know something about chiropractic.

The GPs were asked if, in their opinion, chiropractors have a satisfactory education for mainstream medicine. Forty-nine per cent of the respondents in Sweden agreed and 42% had no opinion. In Norway, the corresponding figures were 80% (satisfactory education for mainstream medicine) and 18% (no opinion). Swedish and Norwegian GPs agreed that chiropractors were competent to treat musculo-skeletal conditions (69% and 93% respectively).

The GPs were asked if they thought that chiropractors use unusual terminology, and this was agreed by 11% of the GP’s in Sweden. In Norway 25% of the respondent GPs agreed.

The GPs were asked how they would describe their experiences of chiropractic treatment for their patients. Nearly half (47%) of the Swedish GPs and 66% of the GPs in Norway reported a good experience of chiropractic. Twenty per cent of the Swedish GPs reported to have a variable experience and 12% said that they had bad experience with chiropractic care for their patients. In Norway 27% of the GPs said that their experience was variable and 3% answered that they had a bad experience with chiropractic care. Furthermore, 21% of the GPs in Sweden stated that they have no experience of chiropractic. This figure in Norway was 3%.

Referrals

In Sweden, GPs cannot refer patients to a chiropractor, so for the purpose of this study the questions about referrals in reality translate to a recommendation, rather than a referral for chiropractic care. The GPs were asked if they recommend chiropractic care for their patients and if so, how many times per month?

Forty-three per cent of the GPs in Sweden recommend their patients to see a chiropractor. In Norway, the majority, 79%, refer patients to a chiropractor. The reported rate of recommendation or referral was 1–5 times per month in both countries.

The GPs were asked what types of conditions they commonly refer to a chiropractor. Acute and chronic back pain followed by disc prolapse with uncomplicated neurological symptoms were the most common conditions to refer, for both Swedish and Norwegian GPs. However, more than 20% of the Norwegian GPs referred babies with colic to the chiropractor. This was non-existent in Sweden.

In response to the question about communication, 55% of the Swedish GPs and 67% of the Norwegian GP’s reported that there were poor levels of reporting back to the GPs from the chiropractors.

The common reasons for not referring amongst the Swedish GPs were; poor knowledge about chiropractic, not being sure of the effectiveness of chiropractic treatment and that it was too expensive for the patients. The reasons for not referring for chiropractic care in Norway were that GPs doubted the effectiveness of chiropractic care and that they had insufficient knowledge about chiropractic.

In Sweden GPs most often refer patients to physiotherapists followed by chiropractors and naprapaths. In Norway it was most common to refer patients to physiotherapists followed by chiropractors and manual therapists.

Additional comments

There were twice as many negative comments about chiropractic as there were positive comments from the GPs in Sweden. The negative comments were concerned with chiropractors having different levels of education, over-treating patients and only focussing on short term relief. Also, some of the comments were concerned with the risks associated with chiropractic manipulation. Concerning positive comments, some of the GPs stated that they wanted increased cooperation with chiropractors and that they found manipulation beneficial, especially for low back pain. Five of these GPs also stated that they had great respect for the chiropractors that were trained at the Anglo-European College of Chiropractic.

Opinions and experiences about chiropractic

There are clear differences between the GPs in the two countries concerning their perceived knowledge about chiropractic, with the Swedish GPs reporting poorer knowledge than their Norwegian colleagues. The difference in the age distribution mentioned above may be responsible for this disparity. Perhaps the younger GPs are more aware of complementary medicine? There might also be educational differences between the younger and older GPs influencing the knowledge of chiropractic. An alternative explanation may be that in Sweden there are fewer chiropractors relative to the size of the population compared to Norway, which makes the Swedish GPs less exposed to chiropractic which could possibly be reflected in their lack of knowledge about the chiropractic profession.

About half of the GPs in Sweden thought that chiropractic education was satisfactory for mainstream medicine, and 80% of the Norwegian GPs thought so. As there are differences in the educational standards for chiropractors practising in Sweden, the profession is less homogenous which may lead to a perceived variation in the quality of care reflected in the lower Swedish score.

Chiropractic terminology and mainstream medicine terminology are different and this may potentially be problematic. However, very few (11%) of the Swedish GPs thought so, but 25% of the Norwegian GPs were aware of this potential problem. One explanation may be due to protocol differences between the countries when it comes to communication between GPs and chiropractors. In Sweden it is not mandatory for chiropractors to contact the GP after referral, whereas in Norway the chiropractor is obligated to contact the GP under such circumstances, Therefore, more communication is taking place between the chiropractors and the GPs in Norway compared to Sweden, which might explain the differences between the countries for this particular question.

In rating their experience of chiropractic, there were also marked differences between the countries. In Sweden, less than half of the GPs reported a good experience, and 21% stated that they had no experience of chiropractic care. The corresponding figures for the Norwegian GPs were two-thirds with good experience and only 3% had no experience. Again, this could reflect the before mentioned poorer exposure to chiropractic and the variable quality of chiropractic education in Sweden.

Referrals

Chiropractic in Sweden is not part of mainstream medicine and GPs cannot refer patients for chiropractic care in the same way that they refer patients for physiotherapy as chiropractic is not included in the public health care system. Therefore it is challenging to compare referral patterns between the two countries. In Norway chiropractic is accepted as a viable option for patients with musculo-skeletal problems and is recommended by 79% of the GPs. This is almost twice the referral rate as in Sweden. Even if the Swedish GPs would like to refer patients to a chiropractor there are no official channels to do so and some GPs stated that they hesitate to refer patients because of the increased financial burden for the patient.

The conditions for which Swedish and Norwegian GPs refer patients to chiropractors are similar in the two countries. Acute and chronic low back pain with or without radiating leg pain were the conditions chiropractors were deemed competent to treat, which is consistent with the available evidence and for the scope of chiropractic care. The large difference in referrals for paediatric chiropractic care between the countries might be due to the fact that the ban on treating children in Sweden was only recently lifted, thus no tradition exists for this option. It may also be related to differences in recognition of the chiropractic profession in general.

There was agreement between the Swedish and Norwegian GPs that there were poor levels of reporting back to the GP. This pattern is seen in similar studies [9–11]. We speculate that an explanation for the poor levels of reporting back to the GPs might be differences in expectations of when a report is needed. Perhaps the GPs expect a report back for every patient they refer to the chiropractor and the chiropractor only reports to the GP when the patient’s condition change to a non- biomechanical condition that cannot be managed by the chiropractor. This is possibly an area where the chiropractic profession has room for improvement. If chiropractors reported back to GPs more frequently, the knowledge and understanding of chiropractic care would potentially improve.

Poor knowledge and not being certain of the effectiveness of chiropractic care were the most common reasons for GPs in both Sweden and Norway for not referring to a chiropractor. It is likely that poor knowledge and doubtfulness about the benefits of chiropractic care are influenced by each other. The growing evidence base of chiropractic care being effective in the treatment of acute and chronic low back pain, [12, 13] was possibly reflected in the fact that these were the most common reasons for sending patients to the chiropractor. However, there may be other reasons responsible for the fact that many GPs doubt the effectiveness of chiropractic care. As mentioned in the comments, misconceptions about risks associated with chiropractic care, economic reasons and not being up to date with the latest evidence may all play a part. However, investigating these factors further was beyond the scope of this study.

Referring patients for physiotherapy was a very common option for the majority of GPs in both Sweden and Norway. This was an expected finding as physiotherapy has been within mainstream medicine for a long time and the patients in both countries receive financial subsidisation for this type of care.

The negative comments from the Swedish GPs may offer some insight into why the referral rates in Sweden are lower than in Norway. The GPs’ comments about different levels of education are justified because that is the case and a cause for concern in Sweden. To date, there are more chiropractors practicing in Sweden who are graduates from The Scandinavian College of Chiropractic than chiropractors from ECCE accredited colleges. Without a minimal level of academic quality in chiropractic education it might be difficult for the chiropractic profession to convince the medical profession that chiropractic is evidence based, effective and safe.

The comments concerning safety are linked to poor knowledge about the latest evidence. The most recent research suggests that there are very low risks associated with chiropractic manipulation [14].