Background
Complementary and Alternative Medicine (CAM) describes a wide, heterogeneous range of approaches to prevent or treat diseases. The exact definition of CAM has been in considerable debate and has evolved over time[
1]. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as "a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine[
2]." NCCAM also divides CAM into mind-body medicine, biologically based therapies, manipulative and body-based systems, energy medicine, and whole systems approaches such as Ayurveda and Traditional Chinese Medicine[
2]. In 2007, almost 4 out of 10 adults and 1 out of 9 children used a complementary and alternative medicine therapy[
3]. Manipulation by either chiropractors or osteopaths was one of the most commonly used therapies (2.8%) by the pediatric population[
3].
Most research on the use of CAM has focused on the patient perspective. Patient characteristics and reasons why CAM practitioners are sought have been identified[
3‐
5]. Research is lacking about the actual practices of CAM practitioners and sub-specialties within those CAM practitioners, including doctors of chiropractic.
There are currently 17 accredited chiropractic colleges in the U.S. and each of these colleges has a curriculum which includes 4 to 5 academic years with a clinical internship. Licensure laws exist in all 50 U.S. states for doctors of chiropractic. All states also require a passing score in the National Board of Chiropractic Examiners (NBCE) and some states have additional examinations such as ethics and jurisprudence.
Within the chiropractic profession there are opportunities to obtain a clinical specialty, called a diplomate certification, in topics such as clinical neurology, sports chiropractic, nutrition, orthopedics, radiology, rehabilitation, and pediatrics. U.S. chiropractic colleges offer these programs through either part-time post-graduate continuing education courses or full-time residency programs. According to the 2005 Job Analysis of Chiropractic survey, 14% of practicing chiropractors hold diplomate status and an additional 22% stated that they have completed work toward diplomate status[
6], but did not report what diplomate status respondents held. The pediatric post-graduate diplomate program was established in 1993. Graduates earn the pediatric diplomate through 180-360 hours of weekend courses over 2 to 3 years. The purpose of this survey was to describe the characteristics of doctors of chiropractic with a diplomate in pediatrics.
Methods
In April 2009, we performed a cross-sectional survey of doctors of chiropractic who hold a diplomate in pediatrics. The Institutional Review Board at the Palmer College of Chiropractic approved this study.
Study design
The survey was created using SurveyMonkey
©
®, an online survey tool (
http://SurveyMonkey.com). SurveyMonkey allowed electronic self-administration and data collection as well as access to an exact paper replica of the survey. Participants accessed the survey from a website that introduced them to the study and was designed with quick links to information about the authors, frequently asked questions, references, and a link to request a paper version of the survey. Proper functioning of images and links and checks for clarity and content of our questionnaire were pre-tested using clinical research personnel at the Palmer Center for Chiropractic Research. Comments and suggestions arising from this pre-test were incorporated into the final version for study participants.
Sample
The target population was the 218 doctors of chiropractic listed on the International Chiropractors Association specialty Council on Chiropractic Pediatrics (ICA-CCP)[
7], the International Chiropractic Pediatric Association (ICPA)[
8] and the Academy of Chiropractic Family Practice's (ACFP) websites as holding a diplomate in pediatrics[
9].
Data collection
An initial information letter explaining the purpose of the study and providing the uniform resource locator (url) to the website with the direct link to the survey was sent to each chiropractor. They were informed that the survey would take approximately 30 minutes to complete, that only a unique identification number would be accessible with their survey except for the project coordinator, that survey completion was voluntary, and that there were no incentives to complete the online survey. Consent was implied if they completed the survey. A follow-up letter was mailed 4 weeks later to all non-responders, followed by a paper version of the survey sent another 3 weeks later with a self-addressed stamped envelope.
The electronic survey was administered with a set sequence of twenty pages, the exact number of questions ranging from one to seven per page. The paper survey was twenty-six pages long, with the number of questions ranging from one to six per page. The electronic survey did not allow for blank responses, however respondents were given the option "Do not wish to answer" to refuse answering a question. Surveys that were started but not completed were used in the final analysis. We were not able to control for completeness with respondents completing the paper survey.
Information was collected about practitioner demographics, practice characteristics, treatment procedures, referral patterns, and patient characteristics. Because the survey was long we did not ask questions about diagnostic procedures. The questions were designed to compare our data with the job analysis of all doctors of chiropractic performed by the 2005 Job Analysis of Chiropractic Survey[
6]. Types of conditions treated were also collected to compare with the conditions treated with complementary and alternative medicine described in the National Health Statistics Reports[
3]. Data were analyzed using SPSS 15.0 (SPSS Inc, Chicago, IL).
Discussion
During the past two decades, there has been increasing interest in pediatrics in the chiropractic profession resulting in the development of two post-graduate pediatric diplomate programs. These programs were developed by doctors of chiropractic with clinical experience and success in treating pediatric patients. The first program, developed in 1993 by the International Chiropractors Association specialty Council on Chiropractic Pediatrics, offers a Diplomate in Clinical Chiropractic Pediatrics[
7]. Currently it is administrated by the International Council on Chiropractic Pediatrics, which is not affiliated with any chiropractic professional association, but supported by both the International Chiropractors Association and the American Chiropractic Association. In 2002, the second program was established leading to a Diplomate in Pediatrics from the Academy Council of Chiropractic Pediatrics[
9] organized by the International Chiropractic Pediatric Association[
8].
Both pediatric diplomate programs consist of post-graduate weekend courses administered through a chiropractic college's post-graduate department. The weekend courses span 2 to 3 years and do not offer clinical rotations. Topics covered include all aspects of pediatrics from conception through birth, infancy, and adolescence. The goal is for practicing doctors of chiropractic to acquire greater skill and competency with the evaluation, diagnosis, and assessment procedures for the pediatric population, as well as to obtain manipulative therapy skills for this population and clinical conditions with which they present to a chiropractor. The two programs differ in amount of classroom hours (180 to 360 hours), number of examinations (2 orals and 2 written to 1 written), and additional requirements, such as scientific papers/presentations and participation in practice-based research networks. For both post-graduate diplomates, program requirements must be met before one is eligible to sit for their respective certification examination. Examinations are administered by the organization offering the program and are not currently governed by a regulatory body.
The National Board of Chiropractic Examiners (NBCE) performed a job analysis survey of doctors of chiropractic in 2003[
6]. This was a random sample survey of US chiropractors who were in full-time practice. Responding chiropractors were white males (82%) who practice 30-39 hours per week (49%). Over half of their work time was devoted to direct patient care (52.9%). Patients presenting to these chiropractic offices were reportedly white females and between the ages of 31 to 64 (50.8%). Eight percent of the NBCE respondent patients were 5 years of age or younger and 10% were 6 to 17 years old.
Based on the names on the target sample list for our survey, we determined there were 79% females. Our survey was a direct comparison of many items of the NBCE survey and showed triple the number of female providers (74%) with a pediatric diplomate. Although this differs from the NBCE respondents (18% female[
6]), it is similar to naturopathic medicine, another common CAM profession[
10]. Chiropractors from our survey reported their patients are primarily female and white, similar to the NBCE survey. As expected, our respondents had a higher percentage of pediatric patients than the NBCE survey. Chiropractors in our survey spent about 63% of their time in patient care and saw approximately 100 patients per week, compared with the NBCE results of 53% of chiropractor's time spent in patient care[
6].
In 2007, the National Health Statistics Reports (NHSR) used a multistage stratified design survey of the civilian, noninstitutionalized, household population in the United States. Some of the NHSR data were about CAM usage among adults and children[
3], but they did not categorize the practice characteristics of CAM practitioners who treated children. The NHSR survey found that patients presented to manipulative/body based practices with a spectrum of complaints and a wide variety of conditions. The most common conditions reportedly treated in the pediatric population in our study (back or neck pain and head or chest colds) were the same as the NHSR 2007 CAM survey[
3].
Birdee et al used the results from the 2007 NHSR and examined independent associations of CAM use with other factors, such as sociodemographic factors, prescription medication use, delays in health care caused by access difficulties, and common medical conditions/symptoms[
11]. White individuals were more common than non-Hispanic black or Hispanic persons to seek manipulation and bodywork, which was similar to findings in our survey. Birdee et al also found that adolescents with musculoskeletal conditions, abdominal pain and nausea/vomiting used manipulation and bodywork. Chiropractors in our survey reported commonly treating pediatric patients with musculoskeletal conditions and occasionally abdominal pain, but not nausea/vomiting. We also observed that parental use of chiropractic was associated with the child use, consistent with Birdee et al findings with CAM in general.
In a survey of Danish chiropractic practices, Hestbaek et al found that children less than one year of age were the most common pediatric patients and chronic musculoskeletal pain was the most common complaint amongst the older children and adolescents[
12]. These results were similar to the findings in our survey, as well as conditions reported in the NHSR survey.
Although the educational content of the diplomate programs emphasizes referral to pediatric providers, our survey did not show that this was common practice. This low referral pattern is consistent with both the NBCE survey and other chiropractic surveys[
6,
13]. In a recent national survey of pediatricians in the U.S., over 96% believed that their patients were using some sort of CAM therapy[
14]. Sawni and Thomas provided a list of medical problems for which pediatricians referred or considered referring for CAM therapies including chronic problems (headaches, abdominal pain, asthma, pain management), behavioral problems, and neurological diseases (seizures, muscular dystrophy, and cerebral palsy)[
14].
Limitations of the study
In our attempt to collect a comprehensive description of this specialty in the chiropractic profession, the survey length may have inhibited participation. Additionally, by providing respondents with the option for mailing back a paper survey, we were unable to probe for missing data or incomplete responses.
Future Directions
Each chiropractic school offers at least one pediatric course in the core curriculum and there are questions on the national board examination related to the pediatric population. However, the knowledge base and skill of the doctor of chiropractic to treat the pediatric population has not been investigated. Although this survey was not designed to assess the chiropractor skill set for treating pediatric patients, this may be an ideal next step along with assessing the content of the post-graduate examining boards' diplomate examinations.
The results of our survey indicate that providers of chiropractic with a pediatric diplomate treat a wide range of health problems. These results also provide a historical background of this specialty within the chiropractic profession that can be used to identify changes over time in response to increasing research into the safety, efficacy, and cost-effectiveness of chiropractic treatment for the pediatric population.
Conclusions
This mixed mode survey is novel to the specialty of pediatrics within the chiropractic profession. The pediatric specialty is relatively new to the chiropractic profession and enthusiasm has prompted the formation of two diplomate certification programs. These programs provide didactic educational experience through weekend courses over the span of 2 to 3 years. The majority of chiropractors with a pediatric diplomate are females and likely use Diversified, Thompson, and Activator ® techniques on their patients with the addition of cranial and extremity manipulation. They are more likely than other chiropractors to treat young patients who typically present with back or neck pain, head or chest colds, colic, constipation, ear infections and upper respiratory infections. The results of this study can be used as historical information as this specialty continues to grow, and may assist with the development of education of this post-graduate specialty within the chiropractic profession.
Acknowledgements
We are grateful to Clinical Research Fellow Angela Ballew, DC who coordinated our survey to ensure confidentiality was maintained during survey implementation. She coordinated each mailing and communicated with inquiring respondents.
This project was conducted in a facility constructed with support from Research Facilities Improvement Program Grant Number C06 RR15433 from the National Center for Research Resources, National Institutes of Health. KP was supported in part by a fellowship from the National Chiropractic Mutual Insurance Company, Inc
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
KP conceptualized the overall project, designed and directed collection of the original data, analyzed the data, and drafted the manuscript. MH, CL, AH participated in the design of the overall project and manuscript, and quality control. All authors critically edited drafts of this manuscript and approved the final manuscript.