Short summary
We performed two web-based surveys among registered chiropractors in Norway, members of the national chiropractic association. The results from these studies showed that the majority of Norwegian chiropractors are young and that they graduated relatively recently from a European school. Almost all work in private practice, with several health practitioners in the clinic and most of them work full time. Chiropractors’ treatment modalities vary to some extent, but in general, manipulation, soft tissue techniques and exercise advice are most commonly used. Although interdisciplinary cooperation is common with regard to communication, this applies to some health professions more than others, such as physiotherapists (most common) versus medical specialists (least common). Chiropractors appear to recognize, mainly agree with and practice according to a recent Norwegian guideline for back problems [14]. They have, in general, a positive attitude towards research and they are satisfied with their work, although there was some apprehension in relation to the future of the profession.
Methodological considerations
The two surveys had a response rate of 61% and 71%, respectively. This raises some questions as to how representative the responses were in relation to all chiropractors in Norway. However, when demographic data from responders were compared with all the members of the Norwegian Chiropractors’ Association (NCA) (representing more than 90% of all chiropractors in Norway [15]), it was found to be very similar in relation to sex, age and geography.
One of the limitations of these two surveys was that no preparatory pilot study was performed. A pilot study may have revealed some weaknesses in the questionnaire allowing for the creation of a more user-friendly survey instrument, which in turn could have resulted in a lower rate of no response in some of the more complex questions. However, the major parts of the two surveys were based on a previous Danish survey [16], designed by experienced researchers, which could be considered as a test of questions and response alternatives.
In addition, one of the major limitations of the survey was the design itself. Data were primarily self-reported and not based on actual counts in patient files or appointment books, nor were they collected with clinical monitoring procedures. The result of this is that there was probably a higher response rate than there would have been with a more cumbersome data collection technique, but some information provided by the chiropractors would be subjective rather than clearly objective. This lack of precise information made it suitable to report the results in a general way, rather than reporting specific and detailed conclusions.
Some questions had quite a few non-responders. Nevertheless, the proportion of these was always taken into account in the analyses.
Discussion of results
In the past, chiropractors worked almost exclusively as solo practitioners and in private practice. Today, more practitioners work in groups, together with other chiropractors and/or with other health practitioners [16],[17]. This was clearly seen in our study. Still, only very few are employed in hospitals and research positions. The latter is hardly surprising, as there is presently no obvious career path for academic chiropractors, there being no chiropractic university-based (or other) undergraduate program within the country.
Despite the high density of chiropractors in Norway, as compared to other countries, only a few chiropractors reported working part time and none of them were registered as being unemployed. This aspect needs to be closely monitored in the near future as it is anticipated that the number of practitioners will increase considerably in the future.
Practice routines
A wide variety of treatment modalities was reported among the chiropractors. Three major approaches were noted to be used by the majority of the chiropractors. These were: manipulation techniques, soft tissue techniques (mainly trigger point and stretching) and instruction/advice on exercise. This is not surprising as these findings probably best describe the activities of a chiropractor [16]–[23]. Techniques that are not recommended by the clinical guidelines [14],[24]–[27] were not widely used.
Three decades ago almost three-quarters of all new patients presenting with LBP were assessed with radiological procedures in Norway [13], often as a precautionary measure. However, recent guidelines [14] have established clear criteria for when radiologic examinations are acceptable, with the result that there has been a considerable reduction in its use, which is also a similar trend in other countries [28]. As a consequence, today only a few clinics have their own radiological equipment. It could be argued that this is mainly for economic reasons, as modern X-ray equipment is an expensive investment and carries high maintenance costs. However, this study also revealed that there was only a modest degree of referrals for X-rays, so it is evident that chiropractors approve of this modern approach to X-ray examinations.
It is encouraging to see that some chiropractors have started using diagnostic ultrasound, which presents no harm (no radiation, no pain) to the patient. Further, it allows for dynamic examinations of muscles and tendons, allowing perhaps for an increased scope of practice.
Interdisciplinary collaboration
Recent guidelines advise a multidisciplinary approach to the management of long-lasting musculoskeletal problems [14],[25]. The findings in these surveys show that only the minority work in solo practices. This is in contrast to some other countries where about half of the profession were working in solo practices [18]–[20],[22],[23]. Among Norwegian chiropractors, it was more common to work in multidisciplinary settings, often together with other health care practitioners. Nevertheless, clinical settings with direct collaboration with general practitioners and medical specialists were uncommon.
Interdisciplinary communication and meetings were typically found to occur on a weekly basis, however most frequently with physiotherapists and massage therapists. Communication with the patients’ GPs is probably less than optimal, as patient-reports are actually mandatory (by legislation [4]) to the GP. The less than optimal communication from chiropractors to GPs was confirmed in a previous Norwegian study on this topic [11].
Chiropractors in Norway have the right to formally refer patients for medical specialist assessment and to physiotherapists for rehabilitation services. Our results indicate that this generally takes place on a monthly basis, though with wide variation in the frequency. As this legislation was introduced in 2006 [4], it might be too early to determine whether these referral activities are optimal.
Prior to 2006, patients required a referral from a general practitioner in order to be eligible for reimbursement for chiropractic treatment. According to a survey in 1992, at that time, one third of all chiropractic patients were referred from a general practitioner [7]. As this practice was abandoned due to new legislation in 2006 [4], it is not surprising that the present referral rate is much lower. In fact, the official report, in relation to this legislation, documents a reduction of referrals from about 30% to 7% [29]. Similarly, our findings indicate that for the majority of chiropractors, approximately 10% of patients were referred from a general practitioner. This decline is supported by a recent article, indicating that clinical collaboration between Norwegian chiropractors and general practitioners over the last decade was reduced from 35% to 11% [30]. This might seem low, in view of attempts to assimilate chiropractors into the health care sector with this recent legislation. However, one of the main intensions of the new legislation from 2006 was that patients should have direct access to chiropractors without having to consult their GP first. Therefore, the written referrals from GPs to chiropractors are probably at present replaced by more informal recommendations. Hence chiropractors might be unaware that patients have actually been referred.
Knowledge about clinical guidelines
Most chiropractors reported to be familiar with the Norwegian clinical guidelines of low back pain, though almost 1/4 failed to answer this question. When they were questioned on specific items from this guideline, they agreed with most of them. Some disagreement would be acceptable though, as different guidelines also diverge in their conclusions and only a few key elements can be clearly synthesized [24].
Comparison with other European countries
There have been practising chiropractors for about a century in both the USA and many European countries. The European Chiropractic Union, an umbrella organization for chiropractic associations in Europe, is actually more than 75 years old [2]. Despite this long-lasting history of chiropractic in Europe, the development, proliferation and maturity of the profession in the various countries have been heterogeneous, primarily as a result of differences in legislation.
There are several demographic and practice-related differences among the chiropractic professions in Europe. For instance, most countries, including Norway, are still dominated by male chiropractors (between 60-80%) as has been the case for more than 20 years in most European countries [13]. In contrast, the male/female ratio is lower in the UK and Denmark [16],[17]. Interestingly, both these countries have their own chiropractic education institutions, so perhaps easy access to chiropractic education attracts more female students.
