Military Medicine 2006 (Jun); 171 (6): 572–576 ~ FULL TEXT
Luke A. Boudreau, BSc DC; Jason W. Busse, DC MSc PhD (Cand.); Graeme McBride, BSc DC
173 Waterloo Avenue,
Guelph, Ontario, Canada.
This article reports on satisfaction associated with the introduction
of chiropractic services within a military hospital,
through a Canadian Armed Forces Pilot Project. We distributed
a 27-item survey that inquired about demographic information
and satisfaction with chiropractic services to 102 military
personnel presenting for on-site chiropractic services at
the Archie McCallum Hospital in Halifax, Nova Scotia. We provided
a second 3-item survey, designed to explore referral
patterns and satisfaction with chiropractic services, to all referring
military physicians. A multivariable linear regression
model was constructed to explore which factors were associated
with patients’ satisfaction with chiropractic services. The
response rate to the patient and physician satisfaction surveys
was 67.6% (69 of 102) and 83.3% (10 of 12), respectively.
Chronic low back pain accounted for most presentations to
the hospital chiropractic clinic. The majority of military personnel
(94.2%) and referring physicians (80.0%) expressed satisfaction
with chiropractic services. Our adjusted analysis
found that older age (β = –0.37; 95% confidence interval
α0.73 to α0.02) and a presenting complaint of knee pain (
α15.56; 95% confidence interval α29.61 to α1.51) was associated
with decreased satisfaction with chiropractic care.
Although our finding of high satisfaction with chiropractic
services is encouraging, formal studies on functional outcomes
and cost effectiveness of chiropractic care are required
to better inform the role
From the FULL TEXT :
Musculoskeletal complaints have been identified as a substantial
source of morbidity among military personnel,
leading to high attrition rates and retraining costs.1 Back pain
and overuse injuries are major contributors to this problem.1,2
In 1993, the U.S. Congress passed a bill authorizing the Department
of Defense to commission chiropractors, which led to a
pilot project at 10 military hospitals3 that progressed to full
integration of chiropractic practices into the American military
health care system in 2001.4
Canadian Forces members have traditionally accessed chiropractic
services outside the military system and have been paying
out-of-pocket in many cases for these services. Recently, the
Canadian military introduced chiropractic services into its spectrum
of care in the form of a pilot project in one of its largest
military hospitals. This study reports the findings of a survey of
armed forces members attending the Archie McCallum Hospital
at Canadian Forces Base Stadacona, in Halifax, Nova Scotia,
which was designed to investigate patient demographics and
satisfaction with chiropractic services.
On July 5, 2000, a 6-month trial of on-site chiropractic services
was initiated through the outpatient department of the
Archie McCallum Hospital at the Canadian Forces Base Stadacona
in Halifax, Nova Scotia. Two chiropractors (G.M. and
L.A.B.) were contracted to provide all chiropractic treatment.
Chiropractic services were restricted to the treatment of musculoskeletal
disorders and referral from either a general practitioner
or a medical specialist was required to access these services.
Chiropractors were expected to provide the referring
physician with an initial report for the medical file, including
examination findings, clinical impressions, treatment plan and
prognosis. Progress updates were also expected after 10 treatments
on any particular case for further approval of care. Chiropractors
were free to employ any treatment they deemed appropriate
(within their scope of practice) and were encouraged to
work with other hospital departments on shared patients.
Chiropractic scope of practice for the purpose of the trial
included joint manipulation of the spine and extremities, soft
tissue massage, stretches, and instruction on home exercise.
Interferential current and acupuncture were also used as an
adjunct therapy in some instances. Direct access to diagnostic
imaging in the hospital was limited to x-rays, with medical
referral required for computed tomography scan, magnetic resonance
imaging studies or any other diagnostic tests.
Patient Satisfaction Survey
For a 6-week period, beginning on September 1, 2000, each
military personnel presenting for chiropractic services to the
outpatient department of Archie McCallum Hospital was asked
by the attending chiropractor to complete a 27-item survey.
Patients were informed that the purpose of the survey was to
collect data on perception of chiropractic services. Patients were
also informed that their submissions would be anonymous and
they were under no obligation to complete the survey. For those
who consented, a survey was provided and they were asked to
return the completed survey to the outpatient department front
desk personnel within the week.
The timing of the survey was relatively early in the trial (approximately
2 months after initiation); however, sufficient time
was needed for data collection and processing for a 6-month
review of the project required by Formation Health Services at
Canadian Forces Base Stadacona. A report on the pilot was then
sent to National Defense Headquarters in Ottawa, Canada for
The 27-item satisfaction questionnaire used for this study
was adapted from the chiropractic satisfaction survey by Sawyer
and Kassek5 and was approved by Formation Health Services.
The questions in the survey addressed several dimensions of
patient care and environment (Table I). Any questions dealing
with financial aspects of care were omitted, as members of the
Canadian Forces are not required to pay out-of-pocket for health
care provided on-site. The word “doctor” was also changed to
“chiropractor” to prevent any confusion, as patients were often
under concurrent medical care. Each question was accompanied
by a 5-point Likert scale with response options from
“strongly agree” to “strongly disagree”. The total score of the
questionnaire was calculated by adding up the individual scores
(1–5) for each of the 27-questions and could therefore range
from 27 (lowest satisfaction) to 135 (highest satisfaction). For
the purposes of analyses, response options were collapsed into
“agree,” “unsure,” or “disagree.” Respondents were also provided
with space to include additional written comments.
We reviewed the clinical files of all patients who completed a
survey, and abstracted the following information: (1) gender, (2)
presenting complaint, (3) initial time of onset of presenting complaint,
(4) duration of presenting episode, and (5) total number
of visits to the on-site chiropractic clinic. For the purpose of this
study, acute was considered any complaint with duration of 3
months or less on presentation, subacute was considered between
3 and 6 months, and chronic was ≤6 months.
Physician Feedback Survey
We distributed an additional survey to gather physicians’
impressions concerning chiropractic services offered at the hospital
outpatient clinic. The questionnaire was adapted from Verhoef6
and was administered to all 12 referring physicians,
approximately 1 month before the end of the 6-month trial. The
survey consisted of three items, which queried perceived patient
demand for chiropractic care, physician’s reasons for referral to
chiropractic treatment (asked to list their top three reasons),
and physician satisfaction with chiropractic services.
Cronbach's α coefficient was used to determine the internal
consistency of the survey. We generated frequencies for all collected
data and created a linear regression model to assess the
relation of the independent variables to the total score on the
patient satisfaction questionnaire. Briefly, we tested each of the
independent variables in univariable regression models for significance,
and any variable that resulted in a p ≤ 0.10 was
entered into a multivariable regression model. For the purpose
of the multivariable regression model, significance was considered
at p ≤ 0.05. All data were analyzed using the SPSS Advanced
Statistics software package (version 10.0.5, SPSS Inc.,
The response rate for the patient survey was 67.6% (69 of
102). Cronbach’s α coefficient (internal consistency), for all 69
respondents, was 0.91. The first item on the survey asked about
the respondent’s general satisfaction with chiropractic care. The
Spearman correlation coefficient between responses to that
question and the total score on the questionnaire (excluding
that question) was 0.65 (p < 0.001), which provides preliminary
evidence of the construct validity of the questionnaire. For the
survey administered to the referring physicians, the response
rate was 83.3% (10 of 12).
Most patients were male at a mean age of 36.9 ± 8.0 years.
Axial complaints accounted for the majority of presentations
(96.6%), the majority of which were low back pain (51.7%), with
only 3.4% of complaints involving extremities (Table I). The initial
onset of respondent’s presenting complaint was typically
substantial, averaging over 6 years. Of the 61 respondents who
provided data on the duration of their current episode, 41% were
acute on presentation, 3.3% were subacute, and the majority of
complaints were chronic (55.7%). The average number of total
chiropractic treatments per respondent was 5.7 ± 4.1.
The large majority of respondents (94.2%) were satisfied with
their chiropractic care, with none reporting being dissatisfied.
Respondents were 100% in agreement that the office was easy to
get to and that the attending chiropractor treated them with
respect and concern. A large percentage of respondents (97.1%)
agreed that their chiropractor thought that they were important
and was careful to check everything during the examination.
Other areas of high satisfaction included the clinic hours of
operation (98.5%), which was from 7:00 a.m.to late afternoon
(based on demand), and the chiropractor’s ability to answer
patient questions (98.6%). Some respondents (37.6%) either disagreed
that, or were unsure if, their chiropractor’s office had the
appropriate equipment to provide good care (Table II). Comments
provided in the survey indicated, in each of these cases,
noted criticism of the medical treatment tables provided by the
hospital and many respondents suggested that proper chiropractic
tables were needed. Some respondents indicated that
they expected better results from treatment or were unsure if
they should have expected better results (30.3%), and 33.2%
relayed that improvements took longer than expected or that
they were unsure if their time to improvement was too long
Our univariable linear regression models revealed three factors
that were significantly associated with respondents’ satisfaction
with chiropractic care (Table III). All significant variables
were entered into a multivariable regression model, with the
backward conditional model of variable entry. In this adjusted
analysis, only older age (β = –0.37; 95% confidence interval
[CI] = –0.73 to –0.02) and a presenting complaint of knee
pain (β = –15.56; 95% CI = –29.61 to –1.51) remained
significantly associated with lower satisfaction with chiropractic
care (Table III).
With regard to the survey completed by referring physicians,
all respondents perceived a demand from patients for chiropractic
services. The majority were satisfied with chiropractic services
provided (80.0%), with two respondents reporting being
unsure as they had not been involved with the pilot project long
enough to provide comment. The remaining 10 physicians each
indicated their three main reasons for referring to chiropractic
services, which were aggregated into five distinct categories. The
majority of respondents indicated they referred to chiropractic
services for predominantly axial, musculoskeletal complaints (8
of 10), with other reasons being the complaint was unresponsive
to physiotherapy (2 of 10), specific patient request (2 of 10),
waiting list was too long for physiotherapy (1 of 10), and previous
patient history of positive response to chiropractic care (1 of
Our surveys found a high rate of satisfaction with use of
chiropractic services in a Canadian military hospital setting for
both patients (94.2%) and referring medical physicians (80.0%).
All patient respondents agreed that the location of the chiropractic
clinic was easy to get to, suggesting that a hospitalbased
clinic was favorable. Patients also felt they were treated
with respect and concern by their attending chiropractor and
were highly satisfied with the clinic hours of operation and the
ability of the chiropractors to answer questions. Lower satisfaction
among patients was associated with older age and presenting
with a knee complaint. Despite a high rate of satisfaction
with care among patients, one-third of respondents indicated
that they expected better results, were unsure whether they
should have expected better results, and relayed that improvements
took longer than expected, or were unsure whether improvements
had taken too long.
In a Swedish study of 30 chiropractors and 336 patients,
Sigrell7 found that chiropractors and patients had many similar
goals concerning care, but patients had lower expectations of
chiropractic treatment than the chiropractors and greater expectations
of being given advice and exercises. There was also a
trend that patients expected to get better faster than the chiropractors
expected them to. Sigrell did not explore whether fulfillment
of expectations impacts on patient satisfaction.7
In general, low back pain patients tend to be more satisfied
with chiropractic care as compared to other heath providers;8,9
however, clinical outcomes appear to be similar among different
health care providers and Carey et al9 have speculated that the
patient-chiropractor relationship may be responsible for higher
satisfaction. Health attitudes and beliefs of chiropractors and
their patients tend to be similar10 and a number of recent studies
have established that treatment by a chiropractor can provide
substantial nonspecific benefit and that communication of
advice and information to patients accounts for much of the
difference between chiropractic and medical patients’
Scarcity of resources is an accepted reality in health care, and
in addition to patient satisfaction there is a need to consider
both clinical outcomes and economic factors when evaluating
treatment options. Cost-effectiveness studies of chiropractic
care compared to other musculoskeletal care providers have
focused on low back pain, and results have been conflicting.
9,14–18 A recent systematic review that included nine
studies was unable to establish the cost-effectiveness of chiropractic
treatment for low back pain versus medical care, and
several methodological limitations of reviewed trials were noted.
19 A more recent systematic review concluded that chiropractic
management did not lead to a reduction of costs related to
back pain when compared to physiotherapy or an educational
booklet; however, this conclusion was based solely on the results
of 644 patients included in two randomized trials.20 The
largest study done to date that explored the cost-effectiveness of
chiropractic care was a 4-year retrospective claims data analysis
of more than 1 million members of a health care plan,
comparing health care expenditures between those with and
those without chiropractic coverage.21 Access to chiropractic
care was significantly correlated with a reduction in the cost of
caring for neuromuscular complaints and back pain and was
associated with lower utilization of radiography, magnetic resonance
imaging, back surgery, and hospitalization.
As far as we are aware, ours is the first study to explore the
implementation of chiropractic services in a Canadian military
hospital setting. Our findings are limited by our modest sample
size. Although surveys were anonymous and left with front desk
staff upon completion, we cannot exclude the possibility that
some respondents may have felt pressure to provide more favorable
ratings of their chiropractic care. Furthermore, the high
satisfaction scores in our patient survey present challenges to
our linear regression model, as marginal variation in this data
provided limited opportunity to establish associations between
variables. We did not collect data on functional outcomes or
costs, and the practical implications of our high patient satisfaction
rates are not known.
Despite these initially encouraging results, a number of important
questions remain to be answered. It is not known
whether provision of chiropractic services to Canadian military
personnel promotes advantages in functional recovery from
musculoskeletal complaints, or what impact the addition of
chiropractic might have on existing rehabilitation services. Research
on cost-effectiveness and health outcomes should be
conducted to further inform the role of chiropractors in the
Luke A. Boudreau was responsible for conception and implementation
of the study design, collection of the data, and preparation and critical
revision of the final manuscript. Jason W. Busse was responsible for
design and implementation of the data analysis, interpretation of the
data, and preparation and critical revision of the final manuscript.
Graeme McBride was responsible for conception and implementation of
the study design and critical revision of the final manuscript.
No funds were received for the preparation of this manuscript. Jason
W. Busse is funded by a Canadian Institutes of Health Research Fellowship
Kaufman KR, Brodine S, Shaffer R:
Military training-related injuries: surveillance, research, and prevention.
Am J Prev Med 2000; 18: 54–63.
Impact of chronic low back pain on military service.
Milit Med 2001; 166: 607–11.
Integration of chiropractic in the armed forces health care system.
Milit Med 1996; 161: 755–9.
The military and chiropractic: answers to FAQ.
Dynamic Chiro 2004; 22: 15.
Sawyer CE, Kassek K:
Patient Satisfaction With Chiropractic Care
J Manipulative Physiol Ther 1993 (Jan); 16 (1): 25–32
Verhoef MJ, Page SA:
Physicians’ Perspectives on Chiropractic Treatment
J Can Chiro Assoc 1996 (Dec); 40 (4): 214–219
Expectations of Chiropractic Treatment: What Are the Expectations of New Patients Consulting
a Chiropractor, and Do Chiropractors and Patients Have Similar Expectations?
J Manipulative Physiol Ther 2002 (Jun); 25 (5): 300–305
Cherkin, D.C. and MacCornack, F.A.
Patient Evaluations of Low Back Pain Care From Family Physicians and Chiropractors
Western Journal of Medicine 1989 (Mar); 150 (3): 351–355
Carey TS, Garrett J, Jackman A, et al.
The Outcomes and Costs of Care for Acute Low Back Pain Among Patients
Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons
New England J Medicine 1995 (Oct 5); 333 (14): 913–917
Coulter ID, Hurwitz EL, Adams AA, Genovese BJ, Hays R, 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: 291–298
Meeker, W., & Haldeman, S. (2002).
Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine
Annals of Internal Medicine 2002 (Feb 5); 136 (3): 216–227
Hertzman-Miller RP, Morgenstern H, Hurwitz EL, et al.
Comparing the Satisfaction of Low Back Pain Patients Randomized to Receive Medical or Chiropractic Care:
Results From the UCLA Low-back Pain Study
Am J Public Health 2002 (Oct); 92 (10): 1628–1633
Breen A, Breen R.
Back Pain and Satisfaction with Chiropractic Treatment: What Role Does the Physical Outcome Play?
The Clinical Journal of Pain 2003 (Jul); 19 (4): 263–268
Stano M, Smith M:
Chiropractic and Medical Costs of Low Back Care
Medical Care 1996 (Mar); 34 (3): 191–204
Skargren EI, Carlsson PG, Oberg BE:
One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary
management for back pain: subgroup analysis, recurrence, and additional health care utilization.
Spine 1998; 23: 1875–83.
Stano M, Haas M, Goldberg B, Traub PM, Nyiendo J:
Chiropractic and medical care costs of low back care: results from a practice-based observational study.
Am J Manag Care 2002; 8: 802–9.
Kominski GF, Heslin KC, Morgenstern H, Hurwitz EL, Harber PI:
Economic evaluation of four treatments for low-back pain: results from a randomized controlled trial.
Med Care 2005; 43: 428–35.
Shekelle PG, Markovich M, Louie R:
Comparing the costs between provider types of episodes of back pain care.
Spine 1995; 20: 221–7.
Baldwin ML, Cote P, Frank JW, Johnson WG:
Cost effectiveness studies of medical and chiropractic care for occupational low back pain:
a critical review of the literature.
Spine J 2001; 1: 138–47.
Cherkin, DC, Sherman, KJ, Deyo, RA, and Shekelle, PG.
A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture,
Massage Therapy, and Spinal Manipulation for Back Pain
Annals of Internal Medicine 2003; 138: 898–906
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
Archives of Internal Medicine 2004 (Oct 11); 164 (18): 1985–1892
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