J Manipulative Physiol Ther 2001 (Mar); 24 (3): 157–169 ~ FULL TEXT
Cheryl Hawk, DC, PhD
Cynthia R. Long, PhD
Karen T. Boulanger
Palmer Center for Chiropractic Research,
Davenport, Iowa 52803, USA.
Objective: To identify patient and practice characteristics that might contribute to people's seeking chiropractic care for nonmusculoskeletal complaints.
Design: This was a cross-sectional study conducted through the methods of practice-based research.
Setting: Data were collected in 1998-1999 in chiropractic offices in the United States, Canada, and Australia; data were managed by a practice-based research office operating in a chiropractic research center.
Population: The subjects were new and established patients of all ages who visited the participating offices during a designated data collection week.
Data Analysis: Multiple logistic regression was used to examine factors associated with patients' presenting for nonmusculoskeletal chief complaints. Pearson's
test was used to examine associations among practice variables and the proportion of patients with nonmusculoskeletal chief complaints.
Results: A total of 7651 patients of 161 chiropractors in 110 practices in 32 states and 2 Canadian provinces participated; data from 2 Australian practices were included in the totals but not in the analysis. Nonmusculoskeletal complaints accounted for 10.3% of the chief complaints. The following characteristics made patients more likely to present with nonmusculoskeletal chief complaints: being less than 14 years of age (adjusted odds ratio [AOR], 6.9; 95% CI, 5.2-9.1); being female (AOR, 1.5; CI, 1.3-1.8); presenting in a small town/rural location (AOR, 1.9; CI, 1.3-2.7); reporting more than 1 complaint, especially nonmusculoskeletal complaints (AOR, 4.9; CI, 3.9-6.0); having received medical care for the chief complaint (AOR, 3.4; CI, 2.9-4.1); and having first received chiropractic care before 1960 (AOR, 1.7; CI, 1.1-2.4). Practices with the highest proportion of patients with nonmusculoskeletal chief complaints (>17%) were less likely to accept insurance and more likely to be in locations with populations greater than 100,000. They used the most common chiropractic adjustive techniques less frequently and used more nonadjustive procedures, especially diet/nutrition counseling, nutritional supplementation, herbal preparations, naturopathy, and homeopathy.
Conclusions: Drawing on practices with the patient and practice characteristics identified in this study to conduct outcomes studies on nonmusculoskeletal conditions is a possible direction for future research.
Key Indexing Terms: Chiropractic, Practice-based Research, Visceral Disorders
From the FULL TEXT Article:
To build the evidence base of chiropractic, controlled
clinical studies of its efficacy for patients with nonmusculoskeletal
disorders are important. [1–3] As noted in 1997 by
Well-designed randomized controlled trials have demonstrated
the effectiveness of chiropractic manipulation in the
treatment of musculoskeletal disorders . . . but there is no
comparable evidence to support the chiropractic management
of visceral disorders. We are at the point today where
the value of chiropractic intervention in visceral cases is
unproven—neither disproved nor proven . . . Relatively few
patients consult a chiropractor or are referred for visceral
A recent well-designed study of the demographic and
clinical characteristics of chiropractic patients in the United
States and Canada indicated that fewer than 1% of chiropractic
patients seek care for nonmusculoskeletal conditions. 
Thus there is an apparently small pool of patients
from which observations about chiropractic care for nonmusculoskeletal
conditions can be made.
Designing controlled studies of nonmusculoskeletal
disorders is difficult because we do not know which
patients, disorders, and chiropractic techniques should be targeted.  If these factors are not identified, confounding
variables are likely to complicate the study; worse, an
inappropriate patient population or treatment protocol
could be chosen.
The purpose of this study was to identify patient and practice
characteristics that might contribute to people’s seeking
chiropractic care for nonmusculoskeletal complaints. This
will provide information that might be helpful in identifying
future sources of more detailed information about chiropractic
use by patients with nonmusculoskeletal complaints.
Furthermore, identification of such characteristics could be
useful to chiropractic educators and practitioners who are
interested in the application of chiropractic care to a broader
range of health conditions.
Before the implications of this study are discussed, it is
important to stipulate the limitations of any PBR study that
should be kept in mind when results are being considered.
PBR is conducted among volunteer practices and their consenting
patients; data collected from these sources might or
might not be generalizable to the general population. [7–11]
For example, because of the nonrepresentative distribution of
participants with respect to chiropractic college, we were not
able to assess whether this factor influenced practice characteristics.
Another limitation of PBR is that data are collected in
distant participating offices, and it is difficult to ensure that
data are complete—in terms of including all eligible patients
and answering all questions—and accurate—in terms of
assessing patient and doctor self-reports. Our quality assurance
procedures indicated that 8 of the 11 practices assessed
included over 75% of their patients in the study; however, 3
practices included less than 60% of their patients, though these
offices’ underreporting appeared not to be systematic. Thus it
is important to keep in mind that our results reflect only what
we found in the participating practices among patients who
were included in the study. For example, Canadians represented
in this study were much less likely to seek care for nonmusculoskeletal
conditions than were US patients; this finding
might be limited to our Canadian practice sample, which represented
only 2 of the country’s provinces. However, we feel
that the observations that we were able to make about these
practices and patients have important implications for chiropractic
education and practice, as we will discuss next.
First, it is important to note that even though we actively
recruited practices that saw a higher-than-average proportion
of patients with nonmusculoskeletal complaints, such complaints
still account for a relatively small proportion of the
chief complaints — 10.3% overall, individual conditions contributing less than 2% each. However, it is clear that we recruited
a number of practitioners who saw far more patients
with nonmusculoskeletal chief complaints than is common in
most chiropractic practices, so we had an adequate sample size
from which to make comparisons.
The purpose of all comparisons made in this study was to
identify characteristics of patients seeking chiropractic care for
nonmusculoskeletal conditions and of practitioners associated
with such patients. We thus investigated 2 main types of characteristics:
those of patients and those of practices/practitioners.
The patient demographic characteristics associated with
seeking care for a nonmusculoskeletal complaint were sex and
age. In general, female patients were more likely to present
with a nonmusculoskeletal condition; it is possible that women
in general are more open to seeking complementary care.
However, patients aged 14 years and under, particularly if they
were male, were far more likely than any other age group to
report a nonmusculoskeletal chief complaint (AOR, 8.6 for
females and 9.5 for males). Although the data are limited by
the unavailability of specific ages within this group, from the
available data on chief complaints it appears that the nonmusculoskeletal
conditions represented in this group are among
those that are medically managed through use of medications
which parents may find objectionable (attention deficit disorder/attention
deficit disorder with hyperactivity, asthma, ear
infection, sinus problems) or for which medical treatment is
not generally offered (upper respiratory infections, enuresis).
It has been hypothesized among DCs that the result of educating
patients about the value of chiropractic for problems
other than musculoskeletal pain will be that patients who originally
seek care for musculoskeletal complaints will later seek
care for nonmusculoskeletal complaints. In addition, it has
been hypothesized that a patient with a musculoskeletal chief
complaint will often have additional nonmusculoskeletal complaints
for which he or she also seeks care. We were able to
address these hypotheses in a limited fashion in this cross-sectional
study by eliciting self-reporting of 3 complaints and
information on duration of the complaints and the length of
time that patients had had any experience with chiropractic. It
appears from our results that:
Patients reporting additional complaints, particularly if
they were nonmusculoskeletal, were more likely to present
with a nonmusculoskeletal chief complaint.
Duration of the chief complaint was not associated with
seeking care for a nonmusculoskeletal complaint; however,
patients who did not specify a duration were more likely to
have a nonmusculoskeletal complaint—perhaps because
many such complaints (eg, fatigue) have an indeterminate onset.
After age was adjusted for, length of time since the first chiropractic
experience was significant only for patients who
first sought chiropractic care before 1960; this may indicate
either characteristics of chiropractic practice in that era or
attitudes or other characteristics of those patients.
Our results showed that patients receiving care from an MD
for their complaint were more likely to have a nonmusculoskeletal
chief complaint and that those receiving only chiropractic
care were less likely to have a nonmusculoskeletal
chief complaint. This finding supports what has been found in
other studies13: that people often seek complementary health
care, such as chiropractic, in addition to medical care. It does
not support the hypothesis that DCs serve as primary care
providers for conditions other than musculoskeletal ones.
Several practice and practitioner characteristics varied
considerably in relation to the prevalence of patients seeking
care for nonmusculoskeletal conditions. Although we were
able to assess patient volume only in solo practices, there
was still an indication that lower volume might be associated
with a higher prevalence of nonmusculoskeletal complaints;
this would bear further study of a more controlled nature.
Practices that accept insurance, including Medicare and Medicaid as well as private insurance, clearly had fewer
patients reporting nonmusculoskeletal chief complaints.
As regards services offered to patients, there were pronounced
differences between practices with a high proportion
of patients reporting nonmusculoskeletal complaints and those
with a low proportion of such patients. First, HI-non-MS practices
used more uncommon chiropractic adjustive techniques.
The most commonly used techniques in the United States are
Diversified, Gonstead, Flexion-Distraction, and Activator ;
these were also the techniques most commonly noted in this
study, with the exception of Flexion-Distraction, which was
not represented at all. The 3 most commonly used techniques
were used less in HI-non-MS practices. Second, HI-non-MS
practices used considerably more nonadjustive procedures,
especially those related to nutrition, herbs, and supplements,
whereas HI-MS practices used fewer nonadjustive procedures,
with two notable exceptions: physical modalities and exercise.
From these results we infer that DCs who provide a broader
scope of chiropractic practice—one that includes (in addition
to chiropractic adjustments) nutrition and other complementary
and alternative procedures, such as homeopathy,
acupressure, acupuncture, and naturopathy—attract patients
who have nonmusculoskeletal health problems, frequently
ones with complex or poorly understood etiologies that are
not completely managed exclusively through use of medical
care. Drawing on the pool of DCs with this orientation to
conduct outcomes studies is a possible direction for future
research investigating the impact of complementary and
alternative therapies on such conditions in a real-life setting.