Chiropractic student choices in relation to indications, non-indications and contra-indications of continued care

This is a secondary analysis of a study that has been reported in full elsewhere and is available as free full text online [18]. Two questionnaires on neck pain [19] and low back pain [20] were included in a survey on the association between psychological profiles and practice patterns, conducted towards the conclusion of the academic year (October and November) in 2016 [18]. The questionnaires have been previously used to assess chiropractors’ clinical decision-making profiles [19‐22]. Participants were chiropractic students from two chiropractic programs at two universities (Programs A and B) in Australia and the original research project required data from all the years [18]. For the purposes of this present study, only data from the third to the fifth years were included, as it was deemed that students in Years 1 and 2 did not have the clinical knowledge to understand the case scenarios used.

Ethics approval was granted by Murdoch University (Project No 2016/118) and the project was classed as a negligible risk research. The project followed the same protocols in both institutions, consent was obtained from students, data were non-identifiable (anonymous) and permission was obtained from the Head of the other chiropractic program to conduct the survey. Accordingly, the study met the criteria for classification under the Australian National Statement on Ethical Conduct of Human Research (2007) (Sections 5.1.8 and 5.1.22) as exempt from requiring ethics approval from both universities.

Information on various demographic details of the participants was obtained (chiropractic program, sex, year of study).

Data were entered and analysed in SPSS v.22 (IBM Corp, Armonk NY, USA) after identifying and correcting any incomplete or corrupt data. Survey items were dummy variable coded.

Responses to the two questionnaires were shown for general information but were not further discussed in this report. These were shown in tables, in which the “correct” answers were highlighted and the most commonly selected answers indicated in bold.

For the purpose of finding answers to our specific research questions, we selected items that most clearly would require care or that could be considered non-indications or contra-indications to continued care. Percentages were calculated for each of these responses and reported by year of study.

Thereafter, all correct answers for the ‘indicated’, ‘non-indicated’ and ‘contraindicated’ scenarios were displayed in a table as percentages together with their 95% confidence intervals (CIs).

Confidence intervals provide information about a range in which the true value lies with a certain degree of probability, as well as about the direction and strength of the demonstrated effect. This enables conclusions to be drawn about the statistical plausibility and clinical relevance of the study findings [24, 25].

We expected that Year 5 would have higher estimates than Year 3 and perhaps Year 4. Thus differences in estimates between study years and types of indications were identified and these were considered to be statistically significant if their 95% CIs did not overlap.

Of a possible 142 3rd, 4th and 5th year chiropractic students from Program A, 90 (63%) completed the survey and from Program B 124/ 518, giving a total of 214 students (41%), of which 54% were male (114) (Table 1). Because some students studied across multiple years and the manner in which these data were recorded at Program A, a few participants could not be placed within a specific year.

As reported elsewhere [18] there was no difference in the psychological variable scores between institutions or between sexes, whether tested by year of program or for the whole institutional sample. Consequently, the two programs were combined for all subsequent analyses.

The results for the whole questionnaires are shown in Table 2 for the neck pain study and in Table 3 for the LBP study. Results for the research questions are found in Tables 4, 5 and 6.

The percentages of ‘correct’ choices varied between the questions (43 to 100%). There were 7 scenarios reported for students in years 3, 4 and 5. This resulted in 21 scores of which 13 were correct in less than 70% of respondents and 8 in 70% or above of students.

Objective 1

For the three scenarios relating to indications for continuing care, the percentage scores of ‘correct’ choices for years 3, 4 and 5 ranged from 43% to 100%. Thus for nine scores, five were below 80% and four were 80% or above.

The ‘correct’ estimates increased for year of study in all three scenarios (Table 4). This was statistically significant as the 95% Confidence Intervals did not overlap when comparing the 3 years of study in these scenarios. This was not in a stepwise manner.

Thus, students were comfortable to continue to treat a simple case of uncomplicated neck pain. Likewise, they would continue treating a simple case of neck pain that spreads to the trapezius muscle. Finally, students knew to continue to treat a patient who completely recovered from an episode of LBP with a history of previous episodes.

The percentage scores for the two scenarios relating to stopping ‘non-indicated’ care ranged from 51 and 64%. Two were above and four were below 60%.

The ‘correct’ estimates did not increase for year of study in these two scenarios (Table 5). Specifically, students did not improve in selecting the ‘correct’ choice of stopping ‘non-indicated’ care in a patient without a previous history of LBP, which had recovered completely within two visits from an acute episode. Nor did they do well in the LBP case where there was an absence of improvement for no apparent reason, but probably due to or concomitant to depression.

For the two scenarios that related to ‘contraindicated’ care, ‘correct’ percentages ranged from 45 to 84%. The scores for the LBP scenario were all below 70% while all the neck pain scores were 70% or above.

The ‘contraindicated’ estimates increased with year of study in both scenarios but not significantly. This means that it is possible that students improve in their ability to correctly stop ‘contraindicated’ treatment but that this did not show for a patient who deteriorates with neck pain to develop absence of neck pain or arm pain but has upper motor neuron lesion findings in the lower limbs. Likewise for the LBP case, where the patient does not improve but worsens.

Despite these obvious contraindications to continue care, between 23% (Year 3) and 12% (Year 5) were still prepared to keep on treating the neck and as many as 55% (Year 3) and 32% (Year 5) would continue with the LBP case.

Objective 2. Do students understand equally well when treatment is ‘indicated’, ‘non-indicated’ and ‘contraindicated’.

As can be seen in Tables 4, 5 and 6, for all the 3 years, by far the best responses were for the simple neck pain scenario, which the vast majority considered a good indication for continued care. The second best scenario was the most severe neck profile with findings of an upper motor neuron lesion. Findings in addition to this are reported below.

2 (a) 3rd year chiropractic students;

Students were by far best at detecting an indication for continued care in the simple uncomplicated neck pain scenario (80%). However, the addition of pain in the trapezius was spotted by less than half as an indication (43%). That absence of LBP improvement with probable depression is a non-indication for continued care was understood by 53% and that absence of improvement with worsening of pain was actually a contraindication was understood by only 45%.

2 (b) 4th year chiropractic students;

Again the LBP non-indication and contraindication were not recognised by almost half, 51% and 56% correct answers, respectively. In addition, only 64% acknowledged that the person with LBP, complete recovery and no previous episodes was not an indication for continued care.

2 (c) 5th year chiropractic students;

The fifth year students, however, were very good at knowing when to continue care (88 to 100%), reasonable at understanding that LBP that fails to improve and gets worse is a contraindication to care (68% correct answers) but often unable to identify non-indications (52 and 58% correct answers).

Post hoc analyses of all variables per year of study were done, cross-tabulating all variables in two by two tables, which in general revealed no associations between individuals who gave the incorrect answer in one scenario and an incorrect answer in the others (data not shown).

This appears to be the first study to investigate clinical reasoning in chiropractic students. For this we used two clinical cases, one on LBP and one on neck pain, with different scenarios that indicated that patients should either receive continued care, were unsuitable for continued care because it would be ineffective, or that care was likely to worsen the condition or markedly prevent other necessary treatment, hence contraindicated.

We found that students were good at identifying indications to continue care and that the results, generally, got better with year of study. However, the scenarios that reflected non-indication for continued care had much worse results and did not improve in higher years. Encouragingly, for an obvious contraindicated neck scenario, the results were good from the beginning and got better but for a contraindicated LBP scenario the results started rather badly in year 3 then improved over the program years.

Incorrect clinical choices did not cluster around the same students to a significant extent.

The best results were attained for extreme cases, especially for the neck scenario with pathological sign posts. The LBP cases required decisions without any such ‘hard’ clinical evidence. Rather, they were based on more equivocal symptoms such as the number of past episodes and fluctuating levels of improvement. It is therefore possible that the students, who had little or no clinical experience, would struggle to find the ‘correct’ answers.

The students got better at choosing to continue care but they also considered continued care when this was not indicated. Research with medical students has suggested they become over confident with training [26]. This may be an explanation for this finding in chiropractic students. In fact, students from all years were not good at stopping ‘non-indicated’ care. It therefore seems that the educative process has been unable to prepare approximately half of the students, who were probably of the attitude “try it and see how it goes” for ‘non-indicated care’. Another explanation is that students were not taught when to stop. Some may not regard this as a safety issue or being acutely dangerous but unwarranted treatment has financial implications for the patient and society and runs the risk of entrenching pain behaviours and practitioner dependence if continued for a protracted period. In other words, this invites over-servicing. If this is the case, chiropractic educators may need to face the challenge of training chiropractic students about the more subtle aspects of patient care as well as developing a healthy self-doubt.

As stated in the introduction, CCE accreditation standards have little regulatory expectations of chiropractic programs using the specific terms contraindicated or non-indicated care. A positive step would be the adoption and enforcement of these terms into the standards of CCEs and their inspection processes. Perhaps this could address the genesis of deficient chiropractic practices and profiles, such as a minority of students believing that disease is caused by ‘vertebral subluxation complexes’ and that chiropractic spinal adjustments are an effective primary treatment for diseases including AIDS and cancer [27].

Some chiropractors use so called maintenance care as secondary or tertiary prevention. However there are wide variations in its use [28]. Some have few maintenance care patients while others have many [29]. No doubt, based on common sense there seems to be a consensus for when ongoing care is indicated. This was confirmed in a survey which showed that maintenance care is thought to be useful for patients who improve well with treatment and have a history of repeat episodes [30]. On the other hand, for patients with no past episodes, maintenance care is not indicated, nor is it indicated when there is no improvement [28].

From an educational perspective, it is our observation that clinical chiropractic education centres on the initial screening of patients to avoid contraindications to care. Once this step is achieved then there is emphasis on the technical diagnosis, i.e. where the problem is and how to treat. But perhaps we do not place adequate emphasis on the different clinical trajectories observed or explaining and discussing what to expect and how to match our treatment approach including the cessation of care. This is important as LBP, for example, has several types of trajectories [31‐33] and each should be considered from a common sense point of view, as, generally, there is no evidence on what sort of approach is best for which type of trajectory.

Despite these encouraging results, it is of concern that in our student sample approximately 20% would not stop treatment when there were serious neurological signs present [19]. This suggests that there is scope for future investigations exploring how educators could best construct educational interventions, which address these types of clinical scenarios.

We contend that common sense is a valuable clinical asset and that the discontinuation of care for a non-responsive patient clearly falls into this domain. The fostering of such an approach may go a long way to addressing the perception of over servicing.

None of the five Councils on Chiropractic Education used the term ‘non-indication’ in their accreditation standards. This study suggests that incorporation of the words ‘indication’, ‘contraindication’ and ‘non-indication’ is warranted at this level and may offer an assessable metric for use as an outcome measure for program evaluation and monitoring student progression. Consequently, it has the potential to produce more responsible graduates and enhance the public perception of chiropractic care.