The chiropractic profession in Norway 2011

Demographic data

Among the chiropractors who responded to the survey, 64% were male with the median and mean age of 36 and 38 years respectively and with 70% being below 40 years of age. Almost 4/5 had been in practice for less than 15 years, and only 8% had been in practice for more than 25 years (1% non-responders). The majority were trained in Europe; approximately 40% in the UK and 20% in Denmark; the others in North America (30%) or in Australia (10%) (2% non-responders).

None reported to have a PhD degree, although 2% reported to be involved in PhD programs. In addition, close to 50% reported to have some kind of additional higher education background: 7% at Master’s level (primarily a Master’s degree in Sports) and 18% at Bachelor level. The most frequently reported professional backgrounds were physiotherapy (5%) and nursing (1%) (53% non-responders).

Clinical settings

Almost all chiropractors (97%) worked in private practice settings (3% non-responders). More than half of the clinics were located in an office building, adapted to wheelchair users, with access to an elevator, and in a building with other health practitioners, whereas only 20% practised in small, separate buildings (6% non-responders).

The majority (61%) had more than 4 treatment rooms in the clinic and therefore often practised together with other health practitioners (1% non-responders). In contrast, about one in four practised in solo practices. About 3/4 of the clinics consisted of more than one chiropractor; almost half of the clinics included at least one physiotherapist and one additional health practitioner (usually a massage therapist), but only 10% of the clinics reported to have a general practitioner linked to the clinic (0% non-responders).

About 1/3 of the clinics had access to large, separate exercise facilities or smaller exercise equipment (2/3), but imaging facilities were not common, as only 1/5 had their own X-ray equipment and 12% had diagnostic ultrasound. A mere 1% had magnetic resonance imaging facilities within their clinic setting (6% non-responders).

Practice routines

Among all the chiropractors, one third reported the total weekly workload to be 30–37 hours and another third reported it to be 38 – 45 hours. A further 1/5 reported to work for more than 45 hours per week (3% non-responders). As 38 hours per week is considered full time office hours in Norway, this means that about half of chiropractors reported to work more than full time), whereas less than 10% worked for less than 25 hours per week. The majority of chiropractors (60%) reported to attend to 15 – 20 patients per day. Eighty percent reported spending 30–49 minutes on a first consultation and 60% spent 15–20 minutes on a regular consultation (2% non-responders).

In addition to instruction on home exercises, half of the chiropractors reported to refer patients to physiotherapists either within or outside the clinic. However, only one in five clinics offered some type of group exercise.

The use of X-rays was infrequent, either through referral to hospitals or private centres or (less commonly) within the clinics themselves. However, only 21% of the clinics reported to use radiological imaging on a daily basis. The questions in the survey allowed only one answer per category which might give rise to some under-reporting. For instance, it could be that chiropractors with X-ray imaging facilities in the clinic were still referring patients for more complex imaging at hospitals.

Full spine radiological imaging on a frequent basis (every day or week) was reported by almost 10%, either performed in their own clinic or by referral. The majority of chiropractors (62%) never referred for or reported taking full spine X-ray at all. Referral for MR imaging of patients was reported by more than three-quarters to occur at least every month. Referrals for ultrasound imaging were not as common as for X-ray and MR imaging (7–25% non-responders, several answers possible).

Interdisciplinary collaboration

One in five reported to have interdisciplinary meetings at least every month. The most common health personnel to be engaged in such meetings were physiotherapists and massage therapists, in contrast to regular (monthly) meetings with GPs, which was reported to occur by only 20% of these (24% non-responders).

With regard to referrals, 3/4 of the chiropractors reported to refer patients to physiotherapists every month (as formal referral) and half of all chiropractors referred patients to orthopaedic specialists, 1/3 to neurologists, and 1/6 to rheumatologists, at least every month (4–12% non-responders, several answers possible). Communications to other health personnel were either written or verbal and for most occurred less than 5 times per week (6–22% non-responders, several answers possible). Chiropractors reported to engage infrequently with certain health personnel such as nutritional therapists and manual therapists. The vast majority (86%) reported the desire to have stronger and better cooperation with other health professions (6% non-responders).

Patient demographics

About half of the chiropractors reported both that less than 10% of their patients were referred from general practitioners and other health personnel. Almost 4/5 reported that less than 10% of their patients were below 10 years of age. In addition, as many as 3/5 reported that between 10-50% of their patients had problems unrelated to the spine (5-7% non-responders, several answers possible).

Attitudes to and knowledge of clinical guidelines

Clinical research participation

Only 5% were involved in Master’s programs and 4% were engaged in various research projects. However, almost 1/3 reported to be willing to participate in clinical research projects depending on the demands on their resources (e.g. extra time in relation to data collection) and compensation (economic or merit). Ten percent reported to be positive about participating in research-related projects regardless the circumstances (8 - 15% non-responders, several answers possible).

Work satisfaction

Almost all chiropractors (90%) reported to be content with their choice of profession. Furthermore, the greater majority expressed that they had sufficient professional challenges and felt that their income reflected their workload. Nevertheless, more than half were uncertain or negative with regard to working conditions in the future (5-8% non-responders, several answers possible).

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.