Military Medicine 2019 (May 1); 184 (5-6): e344–e351 ~ FULL TEXT
Silvano A. Mior, Ellen Voge, Deborah Sutton, Simon French, Pierre Côté, Margareta Nordin, Patrick Loisel, Audrey Laporte
Department of Research and Innovation,
Canadian Memorial Chiropractic College,
6100 Leslie Street, Toronto,
INTRODUCTION: Musculoskeletal (MSK) conditions have a significant impact on the health and operational readiness of military members. The Canadian Forces Health Services (CFHS) provides a spectrum of health services in managing Canadian Armed Forces (CAF) personnel health care needs with on-base and off-base services provided by civilian and uniformed health care professionals, including chiropractors. Although chiropractic services are available in US DoD and VA systems, little is known about the facilitators and barriers to integrating on-base chiropractic services within the CFHS. This study explored key informants' perceptions of facilitators and barriers to the integration of on-base chiropractic services within the CFHS.
METHODS: We conducted a qualitative study to describe and understand how an integrated chiropractic service could be designed, implemented, and evaluated within the current interdisciplinary CFHS. Telephone interviews were conducted, using a semi-structured interview guide, to explore key informants' perceptions and experiences of chiropractic care within the CFHS. In total, we invited 27 individuals across Canada to participate; 15 were identified through purposeful sampling, 12 through a snowball sampling technique, and 2 declined. The 25 participants included military personnel (52%), public servants and contractors employed by the Department of Defense (24%), as well as civilian health care providers (24%). All participants were health care providers [physicians (MD) (7), physiotherapists (PT) (13), chiropractors (DC) (5)]. Interviews were audio-recorded and transcribed verbatim. Transcripts were prepared and analyzed using an interpretivist approach that explored key informants' perceptions and experiences.
RESULTS: Qualitative analysis revealed numerous facilitators and barriers to chiropractic services in the CFHS. These were categorized under three broad themes: base-to-base variations, variable gatekeeper roles, and referral processes. Barriers to integrating chiropractic services included: lack of clarity about a chiropractor's clinical knowledge and skills; CFHS team members' negative prior experiences with chiropractors (e.g., inappropriate patient-focused communication, clinical management that was not evidence-based, ignorance of military culture); suboptimal bi-directional communication between CAF personnel and DCs across bases; and wide-ranging perspectives pertaining to duplication of services offered by PTs and DCs in managing MSK conditions. Facilitators associated with the integration of chiropractic services within a collaborative and interdisciplinary CAF environment included: patient benefits associated with multiple approaches utilized by different providers; adoption of up-to-date, high-quality evidence and guidelines to standardize care and curtail "dependency" between patient and providers; and co-location of providers to strengthen existing interprofessional communication and relationships. Key informants called for patient care that is collaborative, integrated and patient-centered, rather than "patient-driven" care; civilian providers understanding and respecting military culture rather than assuming transferability of patient management processes from the public civilian sector; standardization of communication protocols and measures to evaluate outcomes of care; and the need to move slowly and respectfully within the current CAF health care system if planning the on-base implementation of chiropractic services.
CONCLUSIONS: This study illuminated many opportunities and barriers, in complex and diverse domains, related to introducing collaborative chiropractic services in the Canadian Forces Health Services (CFHS). The findings are relevant to increasing understanding and strengthening interprofessional collaborative care within the unique Canadian Armed Forces (CAF) health care delivery system.
KEYWORDS: Chiropractic; Health Services; Military Medicine; Military Personnel; Rehabilitation Services
From the FULL TEXT Article:
Musculoskeletal (MSK) conditions have a significant impact
on the health and operational readiness of Canadian Armed
Forces (CAF) personnel.  MSK conditions are the most
common reason for CAF personnel not being deployed. 
Further, MSK injuries are responsible for 42% of all medical
releases.  Specifically, back pain is one of the most common
reasons for soldiers not being deployed and is the second
most common activity-limiting acute injury. [2, 4] In 2013, 12%
of CAF regular force medical releases were attributed to
lumbar injuries.  When symptoms persist, chronic back pain
may impact many aspects of a CAF service member’s life,
including: physical deconditioning; excessive use of prescription
drugs; marked dependence on health care providers,
spouse and family; withdrawal from social context; and
continued functional impairment.  The effective and costeffective
management of back pain is an important issue for
individual members and the CAF as a whole. 
“Caring for Canada’s Ill and Injured Military Personnel,”
a report of the Standing Committee on National Defense
(2014) heard evidence about chiropractic services offered to
US Military Health System (MHS) personnel and its impact
on keeping soldiers at work.  The US MHS under the
Department of Defense (DoD) included chiropractic services
for active duty military personnel following the completion
of an initial demonstration project in 1995. [8, 9] Currently, chiropractors
provide conservative care, in cooperation with various
health care providers, in primary care, physical therapy,
orthopedics and sports medicine.  Chiropractic care is provided
on referral and within a set of privileges established
within each system and facility.  Two studies suggest significant
improvements in pain, function, global improvement
and satisfaction with care in samples of active duty military
personnel receiving chiropractic care and standard medical
care as compared to those receiving standard medical care
alone. [11, 12]
Currently, the Canadian Forces Health Services (CFHS)
provides a spectrum of health care services, including care
provided in civilian facilities when services are not provided
on-base.6 Chiropractic care is an eligible CAF health practitioner
benefit when prescribed by a physician, and is
accessed off-base, outside the military health system. Care is
authorized within a 10-visit limit per condition, after which a
physician’s review is required to determine if further care is
Historically in the CFHS, on-site chiropractic care was
available during a 6-month pilot study at a CAF Base hospital,
where two chiropractors provided outpatient chiropractic
care with physicians’ referrals for treatment of MSK disorders.  Care was available in 10-visit increments and supported
with appropriate clinical documentation. Physicians
referred CAF military personnel to chiropractic services for
axial, MSK complaints; if the complaint was unresponsive
to, or the waiting list too long, for physiotherapy; a prior
positive response to chiropractic care; or if the patient
requested chiropractic care.  Patients reported high levels of
satisfaction with their chiropractic care, as well as with office
accessibility, clinic hours and the chiropractor’s ability to
answer questions; none reported dissatisfaction with their
chiropractic care.  Although specific outcomes were not
reported, one-third of patients indicated that they expected
better results or rate of improvement.  Referring physicians
perceived an increased demand from patients for chiropractic
services and they were satisfied with the chiropractic services
The Standing Committee on National Defense in Canada
recommended that a comprehensive MSK strategy be developed
to better understand injury causes, encourage early treatment
and reduce barriers for current soldiers to obtain the
required care.  Although chiropractic services are integrated
into the US DoD system, barriers to integration exist, particularly
if such services are thrust upon them.  Dunn et al identified
barriers to the integration of chiropractic care in the US
MHS, including: work place isolation; lost opportunities to
influence communication; policy and practice without a chiropractor
in a leadership role; precarious employment and
decreased integration of chiropractors within the system resulting
from contractor-status, or employee of a contractor; supervision
by non-chiropractors; and refusal of referral by a
gatekeeper. Facilitators to integration included documentation
requirements in an electronic health record to aid collaboration
between providers and opportunities for clinical education.
In addition to the Standing Committee’s recommendation
of a comprehensive management strategy for MSK, the federal
government’s response suggested “examining whether
earlier interventions by alternative health care professionals
to treat MSK injuries are a workable and worthwhile
approach.”  However, we know little about the facilitators
and barriers to integrating on-base alternative health care
professionals, such as chiropractors within the CFHS.
We employed a qualitative, exploratory research design to
understand and describe key informants’ perspectives on
how an integrated chiropractic service could be designed,
implemented, and evaluated within the current interdisciplinary
Approvals and Recruitment
Ethics approval was received from the Research Ethics
Boards at the University of Ontario Institute of Technology
(# 15-049) and the Canadian Memorial Chiropractic College
(# 152019). Agreement to conduct the study was provided
by the Canadian Deputy Surgeon General, CFHS (7 June
2016). All study participants provided informed consent.
Purposeful sampling16 was used to recruit participants.
Inclusion criteria included: English-speaking health care professionals,
military personnel, and researchers with extensive
experience and in-depth understanding of health care delivery
and interprofessional collaborative practice within the
military setting in Canada. Additional participants with
expert knowledge and/or experience in relation to the delivery
of health care within the CFHS were identified using
snowball sampling technique. 
Interview Schedule and Procedures
Telephone interviews were conducted using an interview guide
with open-ended questions. [17–20] The interview guide was
informed by expert opinion, as well as health, social and behavioral
theories addressing barriers and facilitators to accessing chiropractic
care (See Appendix A). After the first eight interviews,
additional probes were developed and questions slightly revised.
Interviewing continued until the research team ascertained that
saturation of responses to key questions was achieved. [21, 22]
All interviews were conducted by two members of the
research team, both health care professionals, who were not
physicians, chiropractors nor physiotherapists, thereby mitigating
potential researcher bias.  The interviews were conducted
between September 2016 and February 2017 and
were 45-to 60-minutes in duration.
Interviews were audio-recorded, exported to an encrypted
USB key and transcribed verbatim. The project coordinator
reviewed all transcripts for accuracy against the recorded
sessions. Content errors were corrected, and names along
with other potential identifying information removed from
transcripts prior to coding. Each participant was invited to
review and edit their transcript (member checking).
Transcripts were analyzed using an interpretivist approach
that explored participants’ experiences and thoughts. [23, 24]
Each transcript was examined using qualitative content analysis. [25, 26] Categories and subcategories were collapsed and
interconnected to develop meaning and explanation of the
patterns identified in the data.
The analysis proceeded in an iterative and inductive manner.
After the first three interviews were completed and transcribed,
the transcripts were sent to three research team
members who independently coded each transcript. The
researchers then met regularly to review and reach consensus
on coding, examining and defining codes, and developing a
referent codebook. The coding structure and the related transcript
reference data were entered into qualitative data analysis
software (NVivo Pro Version 11.4.1 for Windows, QSR
International (Americas) Inc., Burlington, MA, USA).
Table I provides information on study participants’ professional
backgrounds. Participants included military personnel
(52%), public servants and contractors employed by the
Canadian DoD (24%), and civilians (24%), distributed
across Canada. Military participants included ranks of Chief
Warrant Officer, Captain, Lieutenant, Lieutenant Colonel,
and Colonel. Slightly more than half of the military participants
were deployed at least once over the course of their
career. Participants self-identified as medical doctors (MD),
physical therapists (PT), and chiropractors (DC). The chiropractor
participants, all situated off-base, had recently provided care
for CAF service members. Of the 25 study participants, the
majority were male (n = 76%).
Participants identified barriers (Table II) and opportunities
(Table III), with categories described within each, that could
potentially serve to integrate chiropractic services within the
Barriers to Integrated Chiropractic Services in the CFHS
During the interviews, participants identified a range of factors
and issues that could potentially act as barriers to the
design, implementation and evaluation of chiropractic services
within the CFHS.
Referring to Off-base Chiropractic Services:
“Referring to person, not profession.”
One emergent barrier to integration was the significant
base-to-base variation with respect to referrals to chiropractic
Additionally, notable differences were illuminated
with respect to the critical “gatekeeper” role in the
Care Delivery Unit (CDU) of CAF bases.
Within the CFHS, the function of the CDU is comparable
across all CAF bases; however, they differ in structure and
administrative processes. Such regional variation is consistent
with findings in the Auditor General of Canada report. 
Participants noted that the triage of MSK conditions in sick
parade (military medical triage system that occurs every
morning for patients with acute ailments) varies between bases,
but fundamentally is the responsibility of the CDU Medical
Officer, who acts as the “gatekeeper” for referrals both on- and
off-base. Participants’ recognized the role of medical physicians
in overseeing the primary care of CAF personnel, but noted physicians’
limitations when assessing MSK injuries. Consequently,
at adequately resourced bases, the “lead” physiotherapist or
designate would triage MSK conditions at sick parade, overseeing
the referral process when deemed necessary. A MD
participant explained that within the CFHS, there is no “direct
access” to a chiropractor.
Participants on larger and better-resourced bases, indicated
that Medical Officers may direct uniformed physiotherapists
to make decisions regarding the need for, or appropriateness
of, referrals off-base.
The current way that it works…is that a Medical Officer
can make the recommendation to the physiotherapy
department, but it is ultimately the physiotherapy department
that makes the “yes” or “no” call.
So, from my experience here and at the many previous
postings that I have had, we haven’t really seen a significant
need for chiropractic referral to an external
health care provider for the simple reason that we [physiotherapists]
are able to provide every skill set and
every possible intervention that a CAF member may
require as part of their treatment plan… The odd case
when a spinal manipulation is indicated for a particular
condition such as a fixated facet joint, something of that
nature, where they have a mechanical obstruction that
a low amplitude high velocity mobilization may be beneficial
for, we have the flexibility to refer to a chiropractor
as they specialize in this technique.
As a consequence of base-to-base variations in referral
processes, and variable enactments of the “gatekeeper” role,
the frequency and nature of referrals vary. Specifically, the
decision to refer to chiropractors appears to be up to individual
clinicians rather than based on a systematic approach.
“Never enough information”
Another barrier focused on interprofessional communication,
primarily between on-base physiotherapists and off-base
service providers. Variations in communication processes
were related to available site-specific resources and current
practices. Current practices were influenced by past experiences
and perspectives of the lead CFHS provider(s). In general,
communication, particularly with respect to off-base
referrals, was considered suboptimal. However, some on-base
CFHS providers stated that they made an effort to share relevant
clinical information with off-base providers. In these
situations, a referral note may be followed by a phone call to
the off-base provider. However, standardization of communication
processes in the CFHS was not typical practice:
There has been no effort to try and standardize care
across the country, I think at every base there will be
different interactions between the base and the chiropractors…
So, it is really a one-way communication. We [off-base
chiropractor] get the referral and then I submit an initial
assessment and a progress exam and we don’t
really get a lot of feedback from the military. So,
everything is written, it is by correspondence. There is
really no face-to-face time, or conversations on the
phone. It is all done through email or written reports
that we send by mail.
Similarly, the reports received by on-base CFHS health
care providers from off-base chiropractors, often fell short of
expectations. Participants noted that chiropractors’ reports
often did not include important patient outcomes that are
considered necessary to assess the effectiveness of the care
The biggest problem in the [off-base healthcare providers’]
reports was they said nothing. They would often
say, “Member has benefitted from treatment, recommend
more treatment.” It wouldn’t say, “How has he
benefitted. Is it based on his Oswestry scores? Is it
based on him telling you he feels better? Is it based on
he can now lift 50 lbs. versus before he could only lift
20?” I didn’t know, so there was never enough information
and often when I would ask for information, I
wouldn’t receive it.
Currently, off-base providers cannot access health information
available in service members’ CFHS electronic
health records. Therefore, off-base health care providers are
dependent upon information provided within the referral process
and discharge notes. Participants agreed that addressing
the gaps in bi-directional communication would improve
quality of care and strengthen interprofessional relations.
Duplication of Healthcare Services:
“Blurring scopes of practice”
The third category addressed perceptions and experiences
related to the duplication of health care services involving
physiotherapists and chiropractors. Participants concurred
that over the past decade, the changing scope of practice for
both physiotherapists and chiropractors has significantly
blurred their unique roles. This blurring of roles creates confusion
among patients and health care providers, and a lack
of clarity of the unique role each provider can play.
Over the years, back when I first started being a physio,
there seemed to be a very clear delineation between
physio and chiropractic. But as the years have progressed,
what we have seen is really a conversion of
the two practices, where physios are taught a lot of
manipulative therapy in school now and we continue
that with post grad studies. And chiropractors tend to
do a lot more non-manipulative type of treatment,
whether it be active release therapy or acupuncture or
more exercise based therapy. So, the difference that we
used to see between the two professionals is now a lot
more blurred, and there is a lot more shades of grey
than this clear delineation between the two.
Consequently, participants highlighted perceptions of
duplication and/or redundancy of services as a major barrier
to the integration of chiropractic services. Similar sentiment
was expressed by a minority of North American orthopedic
surgeons, suggesting manipulative care can be provided by
physiotherapists and athletic therapists.28 If chiropractors
and physiotherapists provided similar interventions, and physiotherapists
were already accessible within the CFHS, sentiment
was expressed that there was currently no need to
provide access to chiropractors, regardless of their inclusion
in the CFHS spectrum of care.
So, questions that may need to be answered is what
type of conditions would be referred to a chiropractor
versus a physiotherapist and look at the issue of
redundancy of treatment… are there actually any
additional skill sets which are not currently available
within our practice.
Let’s just be clear on what it is they [chiropractors]
are going to be doing because otherwise there is that
perception of redundancy. The physios are telling me,
“Well, why not just train more physios in manual therapy,”
because those are expensive courses and
because we expect our physios to be deployable and
go to wherever the country asks them to go which
wouldn’t be the case for the chiropractors that we
The preceding quote from a physician illuminates another
potential barrier associated with deployment. Concerns
related to deployment were raised by participants along with
notions of encouraging patient dependency (i.e., perceived
reliance on the health care provider and ongoing care). This
barrier was particularly pertinent when considering that
some contracted services, including chiropractic care, would
not be available during military exercises and deployment.
Opportunities to Integrate Chiropractic Services in the CFHS
Musculoskeletal Disorders: “It’s a significant issue for us”
The first category of opportunities underscored the significance
of MSK conditions currently within the CAF.
It is a big interest at the national level right now to
explore the prevalence and the possible reasons why a
proportion of the patients are referred back. There is
great potential, now more than ever, to look at the
present system of care for low back pain and make
real, cost effective, and concrete changes to how we
deliver this care.
The perspectives shared by participants support the
reported high prevalence of MSK conditions in the CAF.
Participants noted the significance to service members and
how MSK conditions negatively affect the health and wellbeing
of active duty service members, in addition to being a
prevalent source of CAF medical releases. These concerns
are consistent with the CAF report that 43% of regular force
medical releases were attributed to MSK conditions.4
Inter-professional Collaborative Care:
“See the patient from different perspectives”
The second category provided insights into opportunities
to integrating chiropractic services on-base. The notion of
interprofessional collaborative care was considered important
by the majority of participants. Participants thoughtfully
reflected that collaborative care delivered in a team-based
approach provided an opportunity for multiple providers to
contribute to patient care through their unique professional
“lens.” Hence, viewed from this perspective, different professions
could be considered not only for the interventions
they provide but also by their approach to clinical care.29
So, the beauty of collaborative care is that you can
hopefully see the patient from various different perspectives…
a more complete picture, than if just one
person sees them, through the lens of what they tend
Participants shared their perspectives and experiences with
various aspects of care delivery, particularly when involving
chiropractors. The richness of the data and diverse experiences
of the participants provided divergent perspectives of
strategies used to manage back pain. This partly reflects baseto-
base variations, including location, size, resources and primary
purpose. This is highlighted as follows:
Now in [base] I used them [chiropractors] a lot
because we didn’t have a lot of resources. We didn’t
have a lot of physiotherapists, a lot of experienced
physiotherapists. I found the chiropractic very similar
to what I do, very active, not modality based. So, I
trusted them, I trusted their clinical judgment, and so I
used them for that and I used them for manipulation.
So, I think it depends on the base and the resources
available at the base, if that helps”.
Although considered a challenge, such variation also provides
opportunities to implement chiropractic services and
compare health care programs on a national level. For example,
a recent U.S. study reported significant improvements in
pain, function, and satisfaction with care in the group of
active duty military receiving chiropractic care and standard
medical care compared to standard medical care alone.11,12
The third category of opportunities underscored participants’
emphasis on service providers using an evidencebased
approach in determining which interventions should
be included within a program of care. Without exception,
participants advocated for the use of evidence-based interventions,
including use of evidenced-based clinical practice
guidelines. A participant stated:
medicine is very important and there is a whole host of different
I suppose guidelines as such in regards to how you
approach back pain…”
However, some participants could not differentiate
between evidence for an intervention (e.g., manipulation)
and the profession delivering the intervention.
I would say there is a specific need for evidence-based
management of musculoskeletal conditions… Because
that is what the Surgeon General expects…. there is
nothing that chiro offers that is both unique and
evidence-based, so for me it is about providing access
to evidence-based care for MSK issues.
The Spectrum of Care:
“Chiropractic care, we think primarily spine”
The fourth category addressed participants’ knowledge
and experiences pertaining to the “spectrum of care” in the
CAF and the tendency to equate chiropractic care with spine
care. There was consistency among most participants that
access to services within the spectrum of care is for a specific
intervention, rather than for the profession’s full scope
of practice. Similar to other studies, consideration for referral
for chiropractic services was made primarily for spinal
manipulation to treat a spinal disorder, most commonly
chronic low back pain.
So, I think what we recognize chiropractors for the most
are their skill sets in spinal manipulation.
Participants’ perspectives of conditions managed by chiropractors
are similar to that provided in a pilot study conducted
with on-base chiropractors. In this study, almost 97%
of military personnel were referred for spine-related conditions,
of which almost 52% involved the low back.8 A
minority of participants, particularly physicians who had
established both personal and professional relationships with
a chiropractor, considered also accessing chiropractors for
their expert clinical opinion.
“Who ultimately is the spine care specialist?”,
because we lump all kinds of people in that domain. I
think given the nature of the specialty, and how much
time chiropractors spend on the spine, I would have to
agree that…chiropractors,…come closest to a spine
I think that in general when we think of chiropractic
care, we think of primarily spine, spinal, trunk and
sort of mid thoracic trunk problems, and we tend to
think less of them for extremity types of MSK complaints.
The majority of participants called for a delivery
approach involving chiropractors within an integrated team
and founded on a patient-centered spine care model. In this
model, providers are respected and distinguished for their
uniqueness but the care is provided together with others and
not in isolation. Hence, providers do not become the intervention,
but rather health care professionals providing
assessment and treatment, while respecting their scopes of
practices and expertise.
Currently, CAF members have access to chiropractic services
within the spectrum of care and at the discretion of the
referring CFHS providers. Within this context, our study
results inform processes that could address existing challenges
to effective referrals and improve quality of care.
CFHS team members’ lack of clarity about a chiropractor’s
clinical skills and knowledge was a major challenge emerging
from our data. Thus, one recommendation emanating from
key informants’ comments would be establishing personal
relationships (i.e., one-on-one professional contacts with chiropractors),
rather than adopting a broader profession-based
approach, with the goal of enhancing understandings regarding
the knowledge-base and skill set of chiropractors.
This call for a more personal or idiosyncratic approach, as
opposed to relying solely on objective data, was often used to
inform referral practices. In this study, key informants’ experiences
influenced opinions about the value and role of the chiropractor
in managing specific MSK conditions. The reliance
on personal relationships for referral is consistent with previous
research suggesting that despite positive views of chiropractor’s
providing helpful care for MSK conditions, the
diversity within the profession limits referrals and creates barriers
to interprofessional collaboration.28
In our study, the majority of participants appeared to view
chiropractors more as a therapy, specifically manipulation,
rather than as a profession providing comprehensive management
and multiple treatment approaches. This perspective
potentially limited access and timeliness of referrals for care.
A minority of participants, based on personal experience, did
appreciate the chiropractor’s assessment and therapeutic skills.
These differing views of the role of the chiropractor in health
care are consistent with a report by Herman and Coulter29,
highlighting how health policies that define complementary
and alternative professions as individual therapies rather than
as a profession with a wider scope of practice, impacts patient
access and care. A second recommendation emerging from
this study is to explicate the role and responsibilities of the
chiropractor in a collaborative CFHS environment based upon
their professional scope of practice.
Our findings also suggest that the bi-directional
communication between CFHS health care providers and
chiropractors varies between bases but in general is considered
“suboptimal.” Rather than a standardized format
for written and verbal reports, report formats appeared to
be individually developed and base-specific. Negative
experiences (e.g., inappropriate communication, nonevidenced
based clinical management, ignorance of military
culture) may create professional tensions and biases that are
then generalized beyond one-on-one encounters. Such experiences
have been reported in other studies examining the integration
of chiropractors within the US military30 and Canadian
primary care.31 A third recommendation is to standardize and
enhance the level of interprofessional communication to further
continuity of patient care and improve quality care. In addition,
educating non-military personnel about the uniqueness of the
military culture would encourage the development and implementation
of appropriate treatment plans.
Another barrier to integration of chiropractic services is the
perceived certainty of duplication of services, based upon the
“blurring of scopes of practice” between PTs and chiropractors.
Perceived duplication and redundant services were previously
reported as barriers for inclusion of chiropractors in
health care teams (e.g., in sports medicine32,33). Others attribute
such barriers to social constructs related to professionalization34
and the marginalization of professions,35 which impact
boundary disputes and negatively influence collaboration.
Fostering collaborative relationships between chiropractors and
CFHS health care providers, within a patient-centered model of
care, will assist in addressing these barriers.
Our study sample consisted of military personnel, public servants
and contractors of the Canadian Department of National Defense
and civilians. Participants were from different CAF bases, health
care services, and geographic regions across Canada. Military
personnel were of different ranks and military experience.
Nonetheless, individuals who were not invited to participate may
have expressed different views. We also did not explore patients’
perspectives of care delivered within the CFHS nor their experiences
when requesting or being referred for chiropractic services.
Such experiences can significantly impact the inclusion of a
health profession within a health care team.33
This study provided the first qualitative analysis of barriers
and opportunities related to the integration of chiropractic services
within the current CFHS environment. Our findings and
recommendations provide an opportunity to address the current
challenges identified by key informants for the participation
or integration of chiropractors within the unique health
care delivery system of the Canadian Armed Forces (CAF). Further, the findings provide
important information to inform the potential design of an
implementation study to assess the feasibility of integrating
chiropractic services in the CFHS, while strengthening referral
processes to chiropractors within the spectrum of care.
We thank the men and women of the Canadian Forces Health Services for
their contributions to this paper.
This study was funded by a grant from the Canadian Chiropractic
Association and the Ontario Chiropractic Association. The funders did not
have a role in study design, analysis, or preparation of this paper.
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