750 responses were obtained. The average age of participants was 41 (SD=12) with a range of 23-81 (Supplemental Table 1). Graduates from all U.S. chiropractic schools completed the survey. Participants licensed in all 50 states also took part in the survey; however, no chiropractors practicing in Delaware or Alabama completed the survey.
Demographics
The highest number of respondents practice in the Midwest (Supplemental Table 2). We divided respondents into age groups based on generational categories: Silent Generation (born 1925-1945), Baby Boomers (1946-1964), Gen X (1965-1980), Millennials (1981-1996), and Gen Z (1997- present) (Supplemental Table 3). Chiropractors located in a rural setting accounted for 18.5% of respondents, while 26% were located in a small urban setting, 22% in a large urban setting, and 32% in a suburban setting. Urbanicity tends to be somewhat subjective, therefore population was also assessed. Less than 2% practiced in locations with a population of 25,000 or less, 21% practiced in cities with populations between 25,001-100,000 people, nearly 31% in cities with populations between 100,001 and 250,000, and 19% based in cities with more than 250,000 people. The majority of all respondents were located in areas with a population over 25,000, most commonly in an area with a population between 100,000- 250,000. Nearly 28% did not answer this question. State association membership was held by 59% of respondents, while only 47% reported membership in a national chiropractic association.
Practice Characteristics
Nearly half of respondents were sole owners of their practice (47.3%), while just under 20% were owners in a group practice, and another 20% were associates in a group practice. Other roles included administration (5%), hospital provider (3.5%), educator (3.2%), and VA/DoD chiropractor (3.3%). 65.20% of those who responded to this question cared for 100 or fewer patients per week. 22.27% cared for 101-200 patients per week, and 9.73% reported more than 200 patient visits per week. A few responses to this question were potential outliers as some individuals claimed to see between 1150-1500 patients per week; we were unable to interpret if this was mistakenly reported as a total for an entire practice instead of per provider, as indicated in the original question.
When asked to classify their approach to chiropractic, 350 (47%) stated they were strongly evidence-based, 112 (15%) somewhat evidence-based, 221 (29%) both subluxation and evidence-based, 12 (1.6%) somewhat subluxation-based and 48 (6.4%) strongly subluxation-based.
Professional Affiliations
Almost half of respondents were members of a national professional organization (49.6%), while 34.4% said they were not, and 17.6% gave no response. It should be noted that 3 of the respondents answered both “no” and “ACA” as an option for this question and were included in both selected groups. 9 respondents reported being members of both the ACA and ICA. Of those who held membership, the vast majority were members of the American Chiropractic Association (ACA). The most common sources for guidance on professional decision-making during COVID-19 were federal and state governments, local regulations, and colleagues.
Stress
Respondent stress levels related to COVID-19 were also collected. Just over half reported their stress level as moderate (ranging from 4-7 on an 11-point scale), while just over 17% experienced mild stress, and just over 30% felt extreme stress levels (Table 1). The average stress level reported was 6/10. The most common causes of stress were business/employment concerns and financial/economic worries.
Table 1. Stress levels of respondents
STRESS LEVEL
|
Respondents N=750
|
%
|
Low Stress (0-3)
|
133
|
17.73%
|
Moderate Stress (4-7)
|
384
|
51.20%
|
Extreme Stress (8-10)
|
228
|
30.40%
|
The most significant reasons for experiencing stress were business/employment concerns (68%) and financial/economic worries (68%). These far outweighed all other responses. However, other sources of stress included concerns for the patients who could not be seen (41%), the national political response to the pandemic (39%), and fear for the safety of friends and family (33%) (Table 2).
Table 2. Causes of stress
CAUSE OF STRESS
|
Respondents
(n=750)
|
%
|
Child education changes
|
131
|
18
|
Concern for patients unable to be seen
|
305
|
41
|
Family dynamic stress
|
136
|
18
|
Financial/economic worries
|
507
|
68
|
Food/housing insecurity
|
45
|
6
|
General public’s failure to follow guidelines and recommendations
|
185
|
25
|
Global suffering
|
149
|
20
|
Other healthcare providers’ inability to follow guidelines and recommendations
|
129
|
17
|
Personal safety/health
|
158
|
21
|
Political response to virus
|
294
|
39
|
Safety/health of family and friends
|
247
|
33
|
Social isolation
|
155
|
21
|
Worry about staff/co-workers
|
178
|
24
|
When comparing average stress levels to type of position held (owner, associate, etc.), chiropractors working for the VA and DoD reported the lowest stress with a mean stress score of 4/10 and modes of 2/10 and 3/10. Chiropractors working in a hospital setting followed, reporting a mean level of stress of 5/10 (modes 3/10 and 4/10). All other positions had mean scores of 6/10. However mode scores showed more varied central tendency (Figure 1) with associates most commonly reporting 5/10 while the most reported stress level among practice owners was an 8/10 (Supplemental Tables 4 and 5).
Beliefs Toward Spinal Manipulation and Immune Function
Recent graduates (within 1-5 years in practice) were most likely to believe there is no immune system benefit from spinal manipulation. Respondents in practice longer than 10 years were more likely to report that spinal manipulation could improve immune function. The strong majority of respondents (40.18%), regardless of national professional organization affiliation, believed that chiropractic could benefit the immune system; however, they did not feel that there was enough evidence to support actual claims (Supplemental Table 6). Most (76%) agreed that chiropractors should not advertise immune boosting effects of manipulation during the pandemic. However, 13% stated that chiropractors should advertise these effects, while 10% were unsure. 100% of respondents who reported being members of the International Chiropractic Association (ICA) agreed that there was an immune benefit, either proven or not yet proven. This is admittedly a small group overall, only representing about 6.1% of our sample. Conversely, just under 20% of ACA members surveyed do not agree that spinal manipulation can benefit the immune system at all. A higher percentage of ACA members (40.49%) reported a possible benefit to the immune system but agreed that current evidence is not sufficient to support claims. (Table 3)
Table 3. Spinal Manipulation and Immune Function Beliefs and Professional Organization Affiliation
|
ACA (n=326)
|
%
|
ICA (n=46)
|
%
|
Yes, it is proven by research.
|
23
|
7.06%
|
23
|
50.00%
|
Yes, but not enough evidence.
|
132
|
40.49%
|
23
|
50.00%
|
No, but future evidence may provide more insight.
|
97
|
29.75%
|
0
|
0.00%
|
No
|
65
|
19.94%
|
0
|
0.00%
|
Unsure
|
7
|
2.15%
|
0
|
0.00%
|
Note: 9 respondents reported being members of both the ACA and ICA.
Practice Changes due to COVID-19
The relationship between immunity beliefs and the decision to open or close offices during the COVID-19 pandemic was also investigated. Of those who reported chiropractic has a proven effect on immunity, the most popular decision was to remain fully open. Respondents in both groups who felt that future evidence may reveal more insight and that current evidence is insufficient to make claims that spinal manipulation can benefit the immune system were both more likely to remain open with limited hours.
Those who reported that spinal manipulation does not benefit the immune system were more evenly spread across all levels of office closure. This group was also more likely to choose to be fully closed than any other group.
Practice protocols and office changes due to COVID-19 were also investigated. Respondents were able to select multiple options from the following: increased sanitation and overall cleanliness, limited number of people present within the building at all times, limited staff, use of telehealth, use of masks only, use of PPE (masks, gloves, etc.), or no changes at all. Of the 750 respondents, 23.7% did not answer. Of those that answered, 90.40% reported an increase in sanitation and cleaning protocols, 68.9% reported limiting the number of people present in the building at any time, 44.4% reported limiting staff, 24% reported using telehealth services, 26.6% reported only using masks as PPE, and 35.8% reported using masks, gloves, etc. as PPE. Four people reported that no changes were made to practice (less than 1%). When polled about their knowledge on proper use of PPE, 75.7% of respondents reported feeling comfortable.
Telehealth Services and Chiropractic Approach
Out of all 750 respondents, 18.27% reported that they offered telehealth services as a change to normal practice. Of those, the vast majority considered themselves to be “strongly evidence-based” (68.61%) in their approach to the chiropractic profession. Of the 48 who described themselves as “strongly subluxation-based”, only 12.5% reported using telehealth services. This result demonstrates a potential difference in practice style during COVID-19 based on chiropractic approach. Of the 137 chiropractors who chose to offer telehealth services during the pandemic, 59.85% were millennials born between 1981-1996. Gen X respondents were the second most likely population to use telehealth services (28.47%). Baby boomers only represented 10.95% of those offering telehealth services during this time.