The development of working alliance in early stages of care from the perspective of patients attending a chiropractic teaching clinic.

BACKGROUND: The clinician-patient relationship has consistently been found to predict treatment success in both physical and mental health settings. This relationship has been operationalised in the literature as "Working Alliance," which consists of three key components: patient-clinician agreement on the goals of care, agreement on the tasks required to achieve those goals, and the establishment of a strong bond. While research has demonstrated the impact of working alliance in physical health settings, it often measures working alliance early in patients' care journeys. However, no primary research has investigated how early working alliance develops between patients and chiropractors. Evidence suggests that musculoskeletal practitioners may require further training to feel confident in establishing working alliance. Therefore, this study aims to explore the development of working alliance in the early stages of chiropractic care from the patients' perspective to inform evidence-based practice. METHODS: Participants for this qualitative study were recruited from a teaching clinic at a specialised healthcare professions training university in the United Kingdom between September 2022 and April 2023. A total of 25 adult patients completed semi-structured interviews during the early stages of their care. The interview transcripts were analysed using Reflexive Thematic Analysis, from a critical realist stance. RESULTS: The findings highlight that an early working alliance entails the gradual development of patients' confidence in their decision to seek help from trainee chiropractors to alleviate their symptoms. The four themes describe the impact of the clinical context on patients' expectations, the trainee chiropractors' qualities that participants considered important for early working alliance, the role of explanations, and the interplay between pain and early working alliance. CONCLUSIONS: Establishing an early trainee chiropractor-patient working alliance involves a process of building patients' confidence in the trainee chiropractors' expertise, identifying the correct goals of care, and recognising the value of the proposed treatment plan. Factors shaping this process include the context of the care journey, patients' perceptions of trainee chiropractors' qualities, their bodily sensations, their expectations, their past experiences, and their satisfaction with trainee chiropractors' explanations.

Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care.

Objectives: The treatment goals of patients successfully using ongoing provider-based care for chronic spinal pain can help inform health policy related to this care. Design: Multinomial logistical hierarchical linear models were used to examine the characteristics of patients with different treatment goals for their ongoing care. Settings/Location: Observational data from a large national sample of patients from 125 chiropractic clinics clustered in 6 U.S. regions. Subjects: Patients with nonwork-injury-related nonspecific chronic low-back pain (CLBP) and chronic neck pain (CNP). Interventions: All were receiving ongoing chiropractic care. Outcome measures: Primary outcomes were patient endorsement of one of four goals for their treatment. Explanatory variables included pain characteristics, pain beliefs, goals for mobility/flexibility, demographics, and other psychological variables. Results: Across our sample of 1614 patients (885 with CLBP and 729 with CNP) just under one-third endorsed a treatment goal of having their pain go away permanently (cure). The rest had goals of preventing their pain from coming back (22% CLBP, 16% CNP); preventing their pain from getting worse (14% CLBP, 12% CNP); or temporarily relieving their pain (31% CLBP, 41% CNP). In univariate analysis across these goals, patients differed significantly on almost all variables. In the multinomial logistic models, a goal of cure was associated with shorter pain duration and more belief in a medical cure; a goal of preventing pain from coming back was associated with lower pain levels; and those with goals of preventing their pain from getting worse or temporarily relieving pain were similar, including in having their pain longer. Conclusions: Although much of health policy follows a curative model, the majority of these CLBP and CNP patients have goals of pain management (using ongoing care) rather than "cure" (care with a specific end) for their chiropractic care. This information could be useful in crafting policy for patients facing provider-based nonpharmacologic care for chronic pain.

Chiropractic conservatism and the ability to determine contra-indications, non-indications, and indications to chiropractic care: a cross-sectional survey of chiropractic students.

Background: While there is a broad spectrum of practice within chiropractic two sub-types can be identified, those who focus on musculoskeletal problems and those who treat also non-musculoskeletal problems. The latter group may adhere to the old conservative 'subluxation' model. The main goal of this study is to determine if chiropractic students with such conservative opinions are likely to have a different approach to determine contra-indications, non-indications and indications to chiropractic treatment versus those without such opinions. Method: An anonymous and voluntary survey on 3rd to 6th year French chiropractic students was conducted between November 2017 and January 2018. Level of chiropractic conservatism (10 items) and the ability to determine contra-indications (2 cases), non-indications (4 cases) and indications (3 cases) were evaluated through a questionnaire. Answers to these cases were dichotomized into 'appropriate' and 'inappropriate' answers, as defined by previous research teams and the present team. The level of conservatism was classified into four groups, 'group 4' corresponding to the highest score. Descriptive data are provided, and bi- and multivariate analyses were performed through logistic regression to test the associations between the level of conservatism and the ability to determine the suitability of chiropractic treatment. Results: In all, 359 of 536 (67%) students responded to the questionnaire. They generally recognized a number of contra-indications and indications to treatment. However, they found it more difficult to identify non-indications. The more conservative students were more likely to intend to treat their patients, even if this was irrelevant (non-indications). For example, those who were most conservative (group 4) were much more willing than those in group 1 to treat 'chiropractically' a 5-year-old child with no history of back pain or disease to prevent future back pain (OR = 14.7) and also to prevent non-musculoskeletal disease (OR = 22). Conclusion: It is concerning that students who adhere to the subluxation model are prepared to 'operationalize' their conservative opinions in their future scope of practice; apparently willing to treat asymptomatic people with chiropractic adjustments. The determinants of this phenomenon need to be understood.

Introduction: S'il existe de nombreuses approches chiropratiques, deux types de chiropracteurs peuvent-être identifiés; ceux s'intéressant aux troubles musculo-squelettiques et ceux souhaitant prendre en charge aussi des troubles non musculo-squelettiques. Il est possible que ces derniers adhèrent au modèle conservateur de la subluxation. Le principal objectif de cette étude est de déterminer si les étudiants en chiropraxie ayant ce type d'opinions conservatrices ont une approche différente pour déterminer les contre-indications, non-indications, et indications au traitement chiropratique, comparés à ceux n'ayant pas ce type d'opinions. Méthode: Une enquête anonyme et volontaire sur les étudiants en chiropraxie de 3ème, 4ème, 5ème, et 6ème années à l'Institut Franco Européen de Chiropraxie a été effectuée entre les mois de novembre 2017 et janvier 2018. Le niveau de conservatisme (10 items) et la capacité à déterminer les contre-indications (2 cas cliniques), les non-indications (4 cas cliniques) et les indications (3 cas cliniques) ont été évalués. Les réponses à ces cas cliniques ont été dichotomisées en réponses « appropriées ¼ et « non appropriées ¼, comme il avait été défini par les précédentes et l'actuelle équipe de recherche. Le niveau de conservatisme a été classé en quatre groupes, le score le plus élevé étant celui du groupe « 4 ¼. Les données descriptives ont été rapportées, des analyses bi- et multivariées ont été effectuées à travers des régressions logistiques. Le but étant d'évaluer s'il existe des associations entre le niveau de conservatisme et la capacité d'avoir une décision de prise en charge adaptée. Résultats: 359 sur 536 étudiants (67%) ont répondu au questionnaire. Ils reconnaissent correctement quelques cas de contre-indications et d'indications au traitement chiropratique. Cependant, il leur est plus difficile de détecter les non-indications. Les plus conservateurs d'entre eux sont plus sujets à prendre en charge les patients, même si cela n'est pas nécessaire (non-indications). Par exemple, les plus conservateurs (groupe 4) sont plus enclins, comparés à ceux étant dans le groupe 1, à prendre en charge en chiropraxie un enfant de 5 ans n'ayant jamais eu de douleur ou maladies pour prévenir l'apparition de douleurs rachidiennes (OR = 14,7) et de maladies non musculo-squelettiques (OR = 22). Conclusion: Il est préoccupant de constater que les étudiants qui adhèrent au modèle de la subluxation soient prêts à intégrer ces opinions dans leurs futures prises en charge; souhaitant proposer des ajustements chiropratiques aux patients asymptomatiques. Les déterminants de ce phénomène se doivent d'être compris.

Contrasting real time quantitative measures (weekly SMS) to patients' retrospective appraisal of their one-year's course of low back pain; a probing mixed-methods study.

Background: Due to the recurrent nature of low back pain (LBP), the traditional concepts of cure and recovery are challenged, and investigating the course rather than status at fixed time-points may help us understand prognosis as well as treatment effect. However, methods of frequent measuring still need development and validation. Therefore, this study aims to evaluate the agreement between continuous, quantitative self-assessment (weekly SMS) of the course of LBP over a one-year period and qualitatively derived retrospective patient self-appraisal of the same time-period. Methods: Participants were 32 subjects with LBP from primary care. The quantitative measures consisted of weekly SMS questions for one-year about pain intensity, days with LBP, and activity limitations for that week. For each subject, the weekly responses were graphed and categorized into categories based on intensity, variation and overall change patterns. Qualitative measures were based on semi-structured telephone interviews one-year after a consultation for LBP, where two coders independently categorized the self-appraisal of LBP course into the same predefined categories as the SMS-based trajectories. Furthermore, patients' perceived overall recovery was related to variation patterns from SMS track. Results: There was perfect agreement for 48% in the pain intensity domain, 53% in the variation domain and 63% in the change pattern domain. Most of the discordant cases were classified in neighboring categories with the majority relating to fluctuating patterns. The self-perceived overall recovery status seemed to be reflected quite well by the quantitative measures of pain intensity and days with pain in this study. Conclusion: This study shows that a real time quantitative measure (weekly SMS) and the patient's retrospective appraisal do not fundamentally differ in their reflection of the one-year course of LBP.As a first investigation into this area, these results are promising, as longitudinal quantitatively derived trajectories of LBP seem to reflect the lived experience of the patient to a large degree. Furthermore, the patient's ability to retrospectively recall their one-year course of LBP appears to be quite good. Future studies should focus on refining the categories of trajectories.

Stakeholder expectations from the integration of chiropractic care into a rehabilitation setting: a qualitative study.

BACKGROUND: Few studies have investigated patient and provider expectations of chiropractic care, particularly in multidisciplinary settings. This qualitative study explored stakeholder expectations of adding a chiropractor to the healthcare team at a rehabilitation specialty hospital. METHODS: The research methodology was an organizational case study with an inpatient facility for persons recovering from complex neurological conditions serving as the setting. Sixty stakeholders, including patients, families, hospital staff, and administrators, were interviewed or participated in focus groups in June 2015. Semi-structured questions guided the interview sessions which were digitally audiorecorded and transcribed. Data were entered into a qualitative software program to conduct content analysis using an iterative approach to identify key themes. RESULTS: Expectations for the chiropractic program were mostly positive with themes consistently reported across stakeholder groups. The central domain, making progress, encompassed the organizational mission to empower patients to reach hospital discharge and return to life in the community. Higher order goals, characterized as achieving whole person healing, encompassed patients' quality of life, self-efficacy, and activities of daily living. Stakeholders expected the addition of chiropractic to help patients progress toward these goals by improving pain management and physical functioning. Pain management themes included pain intensity, medication use, and pain-related behaviors, while functional improvement themes included muscle tone, extremity function, and balance and mobility. In addition to these direct effects on clinical outcomes, stakeholders also expected indirect effects of chiropractic care on healthcare integration. This indirect effect was expected to increase patient participation in other providers' treatments leading to improved care for the patient across the team and facility-level outcomes such as decreased length of stay. CONCLUSIONS: Stakeholders expected the addition of chiropractic care to a rehabilitation specialty hospital to benefit patients through pain management and functional improvements leading to whole person healing. They also expected chiropractic to benefit the healthcare team by facilitating other therapies in pursuit of the hospital mission, that is, moving patients towards discharge. Understanding stakeholder expectations may allow providers to align current expectations with what may be reasonable, in an effort to achieve appropriate clinical outcomes and patient and staff satisfaction.

Feasibility of the consultation-based reassurance questionnaire in Danish chiropractic practice.

Background: Reassuring information is recommended in clinical guidelines for the treatment of low back pain (LBP), but has not been clearly defined. The Consultation-based Reassurance Questionnaire (CRQ) was developed as a tool for measuring to what extent reassurance is present in back pain consultations and may provide important information about the clinical encounter. Until now the CRQ has only been tested in general practice patients in the UK although many patients with LBP are seen outside of this setting. The objectives of this study were to translate the CRQ into Danish, test its feasibility in chiropractic practice, and determine if CRQ scores were associated with satisfaction with care and perceived pain control. Methods: On the day of the first visit for a LBP episode, patients received an electronic survey including the CRQ. Distributions and completeness of responses on the four subscales of the CRQ (data-gathering, relationship-building, generic reassurance, cognitive reassurance) were assessed, and internal consistency for each subscale calculated as Cronbach's alpha. Outcomes at 2 weeks were; satisfaction with care (5-point Likert scale dichotomised into yes/no) and ability to control pain (0-10). Associations of the CRQ with patient characteristics and outcomes were determined in mixed models to account for dependency of observations within clinics. Results: From 964 patients visiting between November 2016 and October 2017 with new episodes of LBP, 717 completed the CRQ with no more than 1% missing values on any single item. The internal consistency was acceptable for all subscales (0.67-0.86). Scores were generally high, and more so in patients visiting a chiropractor for the first time. All four subscales were positively associated with satisfaction (Odds ratios 1.08-1.23) and generic reassurance was weakly associated with pain control (ß = 0.07 [95% CI 0.03-0.11]). Conclusions: The CRQ was feasible for use in a Danish chiropractic setting and scores on all four reassurance subscales related positively to patients' satisfaction. Patients who had visited a chiropractor previously reported slightly lower levels of reassuring information, and it should be explored if this is in accordance with the patients' needs. The potential impact on patient outcomes needs investigation.

Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.

Objective: To examine patient sociodemographic and clinical characteristics associated with opioid use among Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who receive chiropractic care, and to explore the relationship between timing of a chiropractic visit and receipt of an opioid prescription. Methods: Cross-sectional analysis of administrative data on OEF/OIF/OND veterans who had at least one visit to a Veterans Affairs (VA) chiropractic clinic between 2004 and 2014. Opioid receipt was defined as at least one prescription within a window of 90 days before to 90 days after the index chiropractic clinic visit. Results: We identified 14,025 OEF/OIF/OND veterans with at least one chiropractic visit, and 4,396 (31.3%) of them also received one or more opioid prescriptions. Moderate/severe pain (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.72-2.03), PTSD (OR = 1.55, 95% CI = 1.41-1.69), depression (OR = 1.40, 95% CI = 1.29-1.53), and current smoking (OR = 1.39, 95% CI = 1.26-1.52) were associated with a higher likelihood of receiving an opioid prescription. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before. Conclusions: Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before. Further study is warranted to assess the relationship between opioid use and chiropractic care.

Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team.

Background: While chiropractors are integrating into multidisciplinary settings with increasing frequency, the perceptions of medical providers and patients toward adding chiropractors to existing healthcare teams is not well-understood. This study explored the qualities preferred in a chiropractor by key stakeholders in a neurorehabilitation setting. Methods: This qualitative analysis was part of a multi-phase, organizational case study designed to evaluate the planned integration of a chiropractor into a multidisciplinary rehabilitation team. The setting was a 62-bed rehabilitation specialty hospital located in the northeastern United States. Participants included patients, families, community members, and professional staff of the administrative, medical, nursing, and therapy departments. Data collection consisted of audiotaped, individual interviews and profession-specific focus groups guided by a semi-structured interview schedule. Transcripts were imported into a qualitative data analysis program for data analysis. An iterative coding process using thematic content analysis categorized key themes and domains. Results: Sixty participants were interviewed in June 2015, including 48 staff members, 6 patients, 4 family members, and 2 community members. Our analysis generated a conceptual model of The Preferred Chiropractor for Multidisciplinary Rehabilitation Settings composed of 5 domains and 13 themes. The central domain, Patient-Centeredness, or the provision of healthcare that is respectful, responsive, and inclusive of the patient's values, preferences, and needs, was mentioned in all interviews and linked to all other themes. The Professional Qualities domain highlighted clinical acumen, efficacious treatment, and being a safe practitioner. Interpersonal Qualities encouraged chiropractors to offer patients their comforting patience, familiar connections, and emotional intelligence. Interprofessional Qualities emphasized teamwork, resourcefulness, and openness to feedback as characteristics to enhance the chiropractor's ability to work within an interdisciplinary setting. Organizational Qualities, including personality fit, institutional compliance, and mission alignment were important attributes for working in a specific healthcare organization. Conclusions: Our findings provide an expanded view of the qualities that chiropractors might bring to multidisciplinary healthcare settings. Rather than labeling stakeholder perceptions as good, bad or indifferent as in previous studies, these results highlight specific attributes chiropractors might cultivate to enhance the patient outcomes and the experience of healthcare, influence clinical decision-making and interprofessional teamwork, and impact healthcare organizations.

The Use of the Patient Reported Outcomes Measurement Information System and the RAND VSQ9 to Measure the Quality of Life and Visit-Specific Satisfaction of Pregnant Patients Under Chiropractic Care Utilizing the Webster Technique.

OBJECTIVE: To quantify the quality of life (QoL) and visit-specific satisfaction of pregnant women. DESIGN: A prospective cohort within a practice-based research network (PBRN). Setting/Locations: Individual chiropractic offices. SUBJECTS: Pregnant women (age ≥18 years) attending chiropractic care. INTERVENTION(S): Chiropractic care (i.e., The Webster Technique, spinal adjustments, and adjunctive therapies). MAIN OUTCOME MEASURES: The RAND VSQ9 to measure visit-specific satisfaction and the Patient Reported Outcomes Measurement Information System (PROMIS®)-29 to measure QoL. RESULTS: A convenience sample of 343 pregnant patients (average age = 30.96 years) comprised their study population. They were highly educated with 75% attaining a 2-year associate's degree or higher. The pregnant patients presented for chiropractic care with a mean week of gestation of 25.67 weeks (median = 28 weeks; range = 0-42 weeks) and parity (i.e., the number of live births) of 0.92 live births (median = 1; range = 0-6). From baseline (i.e., at study entrance with minimum first visit) and comparative (i.e., following a course of chiropractic care), the VSQ9 measurements revealed increasingly high satisfaction on the part of the subjects (i.e., the mean difference of baseline minus comparative measures = -0.7322; p < 0.005). The median number of visits (i.e., visits attended) at baseline and comparative measures was 1.00 (standard deviation [SD] = 22.69) and 3.30 (SD = 22.71), respectively. Across outcomes, QoL improved from baseline to comparative measurement after holding constant for visit number and time lapse, trimester of pregnancy, and care provider type. There was a reduction in mean T scores associated with fatigue (p < 0.05), pain interference (p < 0.05), sleep disturbance (p < 0.05), and an improvement in satisfaction with social roles (p < 0.05). A significant decrease was also found with pain interference (p < 0.05). No evidence was found that anxiety (p = 0.1404) or depression (p = 0.8785) changed. CONCLUSION: A PBRN study was successfully implemented among chiropractors to find pregnant patients highly satisfied and their QoL scores improving with care beyond chance.

Do psychological and behavioral factors classified by the West Haven-Yale Multidimensional Pain Inventory (Swedish version) predict the early clinical course of low back pain in patients receiving chiropractic care?

BACKGROUND: To investigate if psychological and behavioral factors (as determined by the Swedish version of the West Haven-Yale Multidimensional Pain Inventory, MPI-S) can predict the early clinical course of Low Back Pain (LBP). METHODS: MPI-S data from patients (18-65 years of age) seeking chiropractic care for recurrent and persistent LBP were collected at the 1(st) visit. A follow-up questionnaire was administered at the 4(th) visit. The predictive value of the MPI-S subgroups Adaptive Copers (AC), Interpersonally Distressed (ID) and Dysfunctional (DYS) was calculated against the subjective improvement at the 4(th) visit and clinically relevant difference in pain intensity between the 1(st) and 4(th) visit. RESULTS: Of the 666 subjects who were included at the 1(st) visit, 329 completed the questionnaire at the 4(th) visit. A total of 64.7 % (AC), 68.0 % (ID) and 71.3 % (DYS) reported a definite improvement. The chance of "definite improvement", expressed as relative risk (95 % CI) with the AC group as reference, was 1.05 (.87-1.27) for the ID and 1.10 (.93-1.31) for the DYS groups, respectively. The DYS and ID groups reported higher values in pain intensity both at the 1(st) and the 4(th) visit. The proportion of subjects who reported an improvement in pain intensity of 30 % or more (clinically relevant) were 63.5 % AC, 72.0 % ID and 63.2 % DYS. Expressed as relative risk (95 % CI) with the AC group as reference, this corresponded to 1.26 (.91-1.76) for the ID and 1.09 (.78-1.51) for the DYS groups, respectively. CONCLUSIONS: The MPI-S instrument could not predict the early clinical course of recurrent and persistent LBP in this sample of chiropractic patients. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863 , February 22, 2012.

Fleas, ruby and the power of chiropractic.

This essay details my experience with a woman who believed her profound incapacity was due to her failure to respect what she termed the power of chiropractic. Whilst the clinical setting may be a fertile locale for the analysis of power the essay seeks not to allocate supplementary relations or uncover unspoken truths by privileging none but a remarkable woman's interpretation of that power.