Our survey of Canadian family physicians found that most report favorable perceptions of chiropractic, including the belief that chiropractic care is effective for some musculoskeletal complaints, provides a useful complement to conventional medicine, and can reduce family practitioner workload. However, attitudes are diverse, and respondents also highlighted several concerns, including lack of evidence-base care, dependency on short-term symptom relief, and vaccine misinformation. Most physicians formed their opinions on chiropractic after medical school, primarily from patients’ feedback, and the majority felt medical training should include information on chiropractic. Most referred some patients for chiropractic care each year, typically in response to requests by patients or because they had not responded to medical care.
Most physicians received requests from chiropractors to refer patients for imaging studies, and wanted to receive consultation notes for shared patients, but the majority also agreed that practice diversity in the chiropractic profession presented a barrier to interprofessional collaboration. Canadian family physician’s attitudes towards chiropractic have remained similar over the past decade. Negative attitudes toward chiropractic care were associated with older age, belief that adverse events are common with chiropractic care, and reported use of the research literature or medical school as a source of knowledge on chiropractic were associated with more negative attitudes. Endorsing a relationship with a specific chiropractor, family and friends, or personal treatment experience as sources of information regarding chiropractic were associated with more positive attitudes.
Strengths and limitations
The strengths of our study include random sampling of all Canadian family physicians, and survey design and conduct consistent with best practices 29. Our assessment of attitudes towards chiropractic was based on the CAQ, which has been validated among other groups of Canadian healthcare providers.23–25 Our study does have limitations, including an overall response rate of 13%, which was lower for the re-administration of the survey. Non-responders may have differed systematically from responders, and the generalizability of our findings to family physicians practicing outside of Canada is uncertain. Our model explained 26% of the variation in respondent’s attitudes toward chiropractic, indicating that there remain additional variables of importance that our survey did not capture.
Relevant literature
In August 2018, the Canadian Chiropractic Association (CCA) published a statement emphasizing a focus on promoting interprofessional collaboration,30 and the CCA advocates for integration of chiropractors into interprofessional health teams 31. We found that although most Canadian family physicians endorse chiropractic care as a useful supplement to conventional medicine, only one in eight physicians reported working with a chiropractor, and practice diversity within the chiropractic profession is perceived as a barrier to interprofessional collaboration.
Most family physicians disagreed that chiropractic care was effective for non-musculoskeletal conditions, and systematic reviews on this topic provide little support to challenge this assertion. 32–35 Most respondents agreed that chiropractic care is effective for certain musculoskeletal complaints, and spinal manipulation, which is commonly provided by chiropractors, has received support for management of axial complaints from recent systematic reviews 36–41 and clinical practice guidelines 42–44. Paradoxically, support from the scientific literature was a common reason given for referral of patients for chiropractic care, while reliance on research literature for information on chiropractic was associated with more negative attitudes. The published literature on chiropractic varies considerably in tone, quality, and findings. Readers of sensationalistically titled case reports (e.g. “Deaths after chiropractic: a review of published cases” 45) are likely to form very different impressions versus less eye-catching, but more rigorously conducted studies on the same topic that arrive at different conclusions.46–48
Close to half of respondents disagreed that chiropractic manipulation of the cervical spine was generally safe; however, although some observational studies have suggested a rare association with stroke,49–51 studies with greater methodologic safeguards against bias have failed to confirm either an association between utilization of chiropractic and risk of stroke,48 or an association between chiropractic care and an increased risk of stroke compared to primary care 46,47. This suggests that associations reported in some studies between chiropractic care and stroke may be due to patients with early dissection-related symptoms seeking care prior to developing their strokes.52–54
Musculoskeletal complaints, particularly low back pain, are common complaints in primary care.55 Our findings suggest that most Canadian family physicians believe chiropractors can provide effective care for some musculoskeletal complaints; however, many physicians do not believe that chiropractors treat in accordance with evidence-based practices and have concerns regarding the safety of cervical manipulation. The chiropractic profession may help address such concerns by continuing to assess the concordance between evidence and practice 56–59 and promoting greater standardization of care where important variability exists. Further research on the benefits and harms of cervical manipulation is needed to establish the appropriate role of this modality.60,61 Improved patient satisfaction and outcomes are associated with interprofessional collaboration among healthcare providers.62,63 Moreover, preliminary evidence suggests that collaboration between chiropractors and physicians for shared patients may reduce use of prescription medication, including opioids, imaging studies, and referrals for surgical consultation.64,65 Efforts to improve relations between family physicians and chiropractors may benefit from increased opportunities to work together and learn from each other.66,67