Results of the sampling
Ten individual interviews were conducted between 13th of September 2019 and 8th of November 2019, lasting on average 17 minutes per interview. Six were conducted at club houses, two at chiropractic clinics, one at a public café and one via telephone. As can be seen from figure 1, below, the sampling process identified instances with and without a chiropractor. However, a third category resulted as clubs employed chiropractors as in-house staff members and external health care providers. An “in-house therapists” was defined as having fixed weekly sessions at the site of the club, where as to the “external service provider” functioned on an ad hoc basis. One health care co-ordinator (HC4) agreed to be interviewed, but became unavailable for a face-to-face or telephonic interview during the data collection period. Interviews with chiropractors and athletes were conducted after interviews of the healthcare co-ordinator of the same clubs had been held.
Figure 1: Flowchart of the sampling process
Thematic framework
Based on participant responses, 14 individual codes were identified and organised into four code families, which included barriers and facilitators. From the codified data, 3 themes were abstracted, these being ‘broadening horizons’, ‘in-house preferred to take-away’ and ‘already covered or even necessary?’. The organisation of the thematic framework is illustrated in figure 2, below.
Figure 2: Organisation of data indicating emergence of themes.
Broadening horizons
Generally speaking, health care co-ordinators engaged the chiropractor’s services with aim of bolstering the expertise level around spine-related problems, but also to gain a different/new approach to assessment and treatment. According to HC 1 and 5:
I found that he would be able to complement me and the other physiotherapists. Particularly with the knowledge of the back and neck. I felt we needed to improve on that subject (HC1; L52-L54).
and
They of course have some special competence regarding manipulation. They have special skills in assessment of, for example, back patients regarding how a back moves, how an SI [sacro-iliac] joint moves and how you assess that… But they just have some other techniques and other approaches, that make it possible to cover the issue in the best way possible (HC5; L44-49).
A different approach was thought to bring other aspects to the pooled knowledge, enabling the IPHCT to make more informed decisions. According to HC1, 2 and 5:
The feedback from the players has been really good but also in the team, where we complement each other well, and something extra has been brought (HC1; L61-62)
Otherwise I would say the overall effect I have felt is that we have gotten an extra pair of hands and it is in regard to sparring and in multidisciplinary teamwork that they have contributed the most to me (HC2; L107-109).
and
I think there was a need for their knowledge and what they could do (HC5; L122).
Added value over previous service provision model was thought to lie in covering a broader spectrum of healthcare, resulting in a greater likelihood of pin pointing ‘the right diagnosis’ (HC5; L47-49). This discourse is highlighted by HC 2 and 3, respectively:
We cover everything, so nothing is left uncertain, because they [chiropractors] have a different sense and a different way of approaching the joints than I do. And it complements each other well, I think. I think we are covering a broader spectrum, also in treatment and I think that is where the gain is (HC2; L114-117).
and
I think it is important to cover a broad spectrum of what you do. We have two physios and a massage therapist now, … and then we send people externally, if we are missing something specific (HC3; L46-47).
Health care co-ordinators engaged chiropractors as spine-related musculoskeletal health experts offering specific discipline-specific knowledge regarding biomechanical injury mechanisms, patient assessment and diagnosis and competencies in conservative manual interventions such as manipulation, mobilization, dry needling. Their rationale for adding the chiropractor is to broaden the shared pool of knowledge with the expressed benefit of better diagnoses and more comprehensive management.
In-house preferred to take-away
Our data indicates that clubs initially made use of the chiropractic service on an ad hoc basis. However, once established, the availability of the chiropractor became an issue for IPP, in particular effective care co-ordination. In this regard, consensus existed that contracting chiropractors as internal service provider, was a distinct improvement compared to earlier ad hoc utilization. This service provision evolution is illustrated in the following discourse from club 2:
… as time went by, I tried to see if we could improve, of course for the football club, but the chiropractors also wanted to contribute more. And then they started to come to the site of the club as well… it has evolved because that worked so well for us. We could make it, so the players were closer to treatment, …, that made it easier for the players and actually for the chiropractors as well, to keep control of things. Instead of seeing the players sometimes, and then not for 2-3 weeks (HC2; L39-47).
The interdisciplinary teamwork is good, especially in the later years where we have attended the training camps, …, that just makes us know each other’s strengths and weaknesses much better. … And it works with equality with respect for each other (CH2; L77-81),
I know that they will come tomorrow, so there he can crack my back and loosen my hip, then I maybe get the massage therapist to do that and that, so that I do not get double treatment… Planning wise it is also easy for us … That is nice” (AT2; L32-37).
From a service delivery perspective, this developing relationship was perceived as beneficial to athletes as service delivery could more readily include curative and preventative care. In this regard HC 1 stated:
… the chiropractor also sees the same people repeatedly and not only when they get injured. Earlier it was only when they got injured. Let’s say they had an acute lumbago, then they would be sent to a chiropractor. Now he is more implemented every day in everything (HC1; L29-36).
A pragmatic benefit of having chiropractors as internal therapists was ‘getting extra pairs of hands’, so that there is ‘more time for immersion’ with each athlete (HC2; L102-104). This view was echoed by HC5, who saw shifting to in-house chiropractic services as a wish list item, stating: “We could use some extra hands and some extra time for immersion” (HC5; L137-138).
For the chiropractor, attaining in-house service provider status provided a clear benefit of direct access to athletes. These benefits included athletes developing a better understanding of ‘what we [chiropractors] are good at and what the physio is good at ‘(CH2; L50-53). Moreover, care could be initiated timeously. In this regard CH1 observed:
… the previous physios were not fans of chiropractors, it was the players who needed to ask to be seen by a chiropractor … That was a problem because then we see the patient too late (CH1; L41-44).
Shifting chiropractors from external to in-house practitioners, provided health care co-ordinators with care continuity benefits. Moreover, having more practitioners available provided an additional advantage to individualized care strategies. And direct access to athletes provided the chiropractor with a better opportunity to timeously initiate appropriate care.
Already covered, or even necessary?
In the two instances of clubs not utilizing chiropractors, services deemed relevant to a chiropractors were instead assigned to an osteopath. In this regard HC6 and 7 stated:
… we have had osteopaths all along in the club instead of chiropractors… which you could argue on some points are similar (HC6; L6-10).
and
We do not have a chiropractor employed, but we have an osteopath employed and a part of the osteopath education is also chiropractic – at least in some ways with manipulations etc… (HC7; L2-3).
For HC7, the osteopath ‘only does manual therapy when he is with us’ (HC7; L32-33) and mainly with a preventative focus. In this regard HC6 and HC7 elucidated this role, stating:
… he [the osteopath] has no part in rehabilitation. The role he has is that some of the long-term injured players – some of them who are maybe back in training, but still have some irritations – I send them to him (HC7; L32-37).
The osteopath covers the preventive correction. What I see as the strength of the osteopath is to look at alignments, the whole person and where there are things that are …, badly compensated …, that we maybe can try to correct and see if it is compensated better before you start with for example strength training and all sorts of other things (HC6; L53-57).
Interestingly both respondents, despite their perceptions of chiropractors and osteopaths overlapping significantly, admitted to having a very limited knowledge of the chiropractors’ scope of practice. Specifically, HC6 and 7 stated:
But I will say, I know nothing about chiropractic (HC6; L72)
and
I do not know very much of the chiropractic education… I do not know the chiropractor’s role in rehabilitation and how good they are at that – and that is probably why it is physiotherapists we employ (HC7; L54-58).
From a practitioner utilisation and cost-effectiveness perspective, HC7 argued that smaller clubs are better off with a lean health care team, rather than attempting to offer extended services. In this regard HC 7 argued that:
This is a club with not that much money… There is [only]money for two full time employees, and I prefer that instead of me being full time and four others sharing the other days, … And from those criteria I think it makes more sense to have two full time physiotherapists where one of them is an osteopath, than having a chiropractor employed (HC7; L14-19)
Finally, the seriousness of spinal problems as factors affecting training and performance in football were questioned and as a result the need for a practitioner with a limited spinal focus. For HC 7: “… we do not experience players who have an issue with their low back being out of training. That is very rare. That is a bit of an injury you must play through… Low back issues are rarely something that keeps our players out – max one to two days” (HC7; L42-44).
Chiropractors are not perceived as professionally unique and some health care co-ordinators share an affinity for other service providers groups that are perceived to provide a service equivalent to chiropractors. In instance of financial limitations co-ordinators may look towards a core provider team that may also be able to provide some of manual therapy options associated with chiropractic. The relevance of a professional group with a niche interest in the spine is questioned in the context of football.
Barriers and facilitators
Based on respondent feedback, we identified 4 barriers and 3 facilitators relevant to chiropractor involvement in this context of practice. These are summarized in table 1. (see also table 1).
Table 1: Barriers and facilitators to chiropractor inclusion in inter-professional practice.
When not included as service providers, we observed two barriers relating to the expertise chiropractors are perceived to offer. Firstly, and in a general sense, back pain was perceived as self-remitting. And as a consequence, the need for a back pain expert was questioned. Secondly, the uniqueness of chiropractors as providers of manual therapy interventions was queried, with occupational groups. Specifically, osteopaths were perceived to have similar utility and were suggested as an alternative.
Professional groups, in this instance physiotherapists, appear to compete with chiropractors for positions as in-house service providers.
Budgetary limitations, again in a general sense appear reduce the level of chiropractor service utilisation. However, perhaps more importantly, it would appear that with a tight health care budget, the co-ordinator is likely to create a lean health care team, composed of providers with known roles.
With regards to facilitators, health care co-ordinators incorporating chiropractic services, endorsed the notion of the interprofessional team, offering a superior health care solution, due to a larger pool of shared knowledge. Moreover, and with a focus on back and neck-related problems, chiropractors were specifically seen as a provider group with an important contribution to offer. Lastly, the utility of chiropractors as part of the in-house provider team, was strongly endorsed by athlete responders. This perspective appears grounded in the need for regular contact with chiropractors to manage long-term health care issues.