This was the first survey of the care approaches of UK chiropractors since 1977 and characterised the care provided, across an initial course of visits, for all new patients who presented with any condition during the data collection period. A key finding was that multimodal packages of care, that included a range of different interventions, were utilised for all presenting conditions. Similar patterns that were seen for all conditions included the extensive use of manual articular and soft-tissue techniques and the prescription of specific or general exercise. Moderate numbers of patients received pain education interventions and acupuncture or dry needling, however few reportedly received psychological approaches. A wide range of additional approaches were reported, although none at high frequency. Chiropractors usually introduced interventions at the first visit and often continued their use across the initial course of care. Although widely used, exercise prescription was more likely than manual techniques to be introduced later in the care plan. Some differences in the care approach for different conditions were identified.
The predominance of manual articular approaches in management of low back pain is consistent with the findings reported in previous studies(29, 31, 45). Similar findings are also reported for low back/spine maintenance care(5) and for care combined across all presenting conditions(2, 27). This is the first study to evaluate levels of use in the management of other conditions and identifies variations in practice, notably lower levels of use in management of upper limb conditions, and a reduced tendency to introduce manual articular approaches at the first visit for arm pain +/- neck pain. Reasons for the latter trend are unclear, but might reflect a greater perceived risk of adverse events for spinal manipulation/mobilisation in the presence of possible cervical radiculopathy. These patients had, on average, more visits than for other conditions, potentially suggesting more severe symptoms, and evidence suggests that higher levels of neck pain are associated with a greater risk of more severe neurologic adverse events following spinal manual therapy(38), which may promote a more cautious approach.
Soft tissue approaches were very commonly included in the package of care for all MSK conditions and headaches, being particularly frequently included in the management of upper limb conditions and headaches. The rates found in this study are higher than those previously reported for chiropractic treatment of all conditions(2), and historically recorded in UK practice for patients treated for low back pain(45). Contributing factors are unclear, but it is possible that increased inclusion of soft tissue approaches reflects awareness of emerging, albeit limited evidence and recommendations for the use of soft tissue approaches for some conditions, including shoulder pain(49) and chronic tension-type headaches(50).
In 1977, only 2–3% of UK patients receiving care for low back pain received exercise approaches(45). This is in contrast to a much higher proportion (61.83%) of patients in this study. This may reflect awareness and implementation of UK clinical guidelines recommending exercise for acute or chronic lower back pain in adults, with or without sciatica(51) and broadly consistent recommendations across low back pain guidelines for education that supports self-management, return to normal activities and exercise and a move away from passive interventions in isolation(52). The UK guideline recommends that manual therapy be considered, but only as part of a treatment package that includes exercise, with or without psychological therapy(51). The findings of this survey indicate that while exercise is widely used, it is not included for all low back pain patients who receive manual therapy, thus there is a need to further enhance guideline-concordant care for low back pain among UK chiropractors. Across the different MSK conditions in this survey, exercise approaches were included in the care package for a majority of patients. This is comparable to a study of practice in Australia(27) where, across all conditions, patients received therapeutic exercise prescription at just over half of visits and or advice about exercises in general at approximately one fifth, and is in the higher range of levels of exercise use as a care approach by chiropractors identified in a scoping review(2). Exercise approaches in this study were somewhat less utilised for the management of patients presenting with headaches than for musculoskeletal conditions. A recent clinical practice guideline that post-dates this present survey recommends exercise interventions for certain tension-type and cervicogenic headaches(53), while two systematic reviews and meta-analyses concluded low-moderate quality evidence that aerobic exercise was effective in reducing migraine burden and episodes(54, 55). There may be a need therefore for chiropractors to further increase implementation of exercise approaches in their management of primary headache presentations.
The use of pain education approaches by chiropractors was greater in this study than previously reported. For example, surveys in Australia(27) and Canada(28) reported very low rates of advice (various types without specification of pain education), at less than 4% of patient encounters. The current study identified similar various types of advice within its open field ‘other intervention’ question at over 60% of all visits. In addition to this, pain education was specifically reported as used for most conditions, with the highest level of use for 1 in 4 patients with leg pain +/- back pain. This might indicate differences in UK practice, however, in this study chiropractors were explicitly questioned about pain education, which might have resulted in greater reporting. Two recent systematic reviews of clinical practice guidelines found consistent recommendations for advice and education for neck pain(56) and low back pain(56, 57), although there remains uncertainty over what should be included and how best to deliver this, with recent studies seeking to develop and evaluate structured education programmes for low back pain(58) and hip and knee osteoarthritis(59). Some studies report benefits specifically of pain education for recent low back(60) and chronic spinal pain(61). However, not all studies report benefits for patient education in low back pain(62). This awareness of recommendations but lack of clarity in what to include and how to deliver education approaches within multimodal chiropractic care may underlie the moderate utilisation levels of pain education reported by chiropractors in this survey. Further studies are needed to evaluate the optimum content and delivery strategy in this setting.
Chiropractors in this survey reported low rates of utilisation of psychological approaches. Defined psychological therapies, such as cognitive behavioural approaches that are recommended for low back pain (NICE) are outside the scope of practice of chiropractors in the UK. However, it was anticipated that chiropractors might report using basic preliminary psychosocial approaches such as discussion with patients of fear avoidance beliefs or barriers to return to work. A limitation of the survey was that ‘psychological approaches’ were not defined and participants may have interpreted these as meaning psychological therapies. It is therefore unclear to what extent chiropractors engage with discussions around psychological factors with their patients.
Few patients presented seeking care for non-MSK conditions, or wellness care, although this was more common in children. Maintenance care(63) would not be captured in this survey as the study period was limited to 4 weeks from first presentation. Robust evidence for effectiveness or efficacy of SMT is lacking for non-MSK conditions(64). The findings of this survey did indicate that manual articular techniques were utilised for non-MSK conditions, albeit at lower rates than for other conditions, while cranial techniques were notably used more often than for other conditions. There was also evidence that for patients who presented with a non-MSK condition or for wellness care as the primary reason for seeking care, chiropractors did not always provide care. There was also a greater tendency to utilise diet/nutrition/lifestyle advice and supportive self-management than for other conditions although due to small numbers of patients, caution should be exercised in interpretation of this data.
The main limitation of this study was its low participation rate among chiropractors compared to other studies with different methodologies. This limits the generalisability of the study’s findings regarding multimodal care to the wider population of UK chiropractors. Participating chiropractors entered data from their patient consultations into the electronic data collection form themselves, which may have been perceived as burdensome. The more resource-intensive method of data extraction from chiropractors’ records by researchers, in line with some other studies(27, 28) may have increased the participation rate. Despite this limitation, graduates of all UK institutions were represented and age and gender characteristics were comparable with the GCC’s register. However it is still possible that selection bias with respect to practice approaches of participants compared with non-participants may exist. An unanticipated finding was the notable lack of representation of chiropractors who graduated outside the UK, with almost no data captured for this group. Factors that underlie this absence of engagement with the study are unclear.