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1Palmer College of Chiropractic WestPalmer College of Chiropractic West
Chiropractic visit observations among a group of patients who received chiropractic care for
acute neck pain
2Palmer College of Chiropractic WestPalmer College of Chiropractic West
Introduction
• Very little information is available regarding the duration of chiropractic care or visit frequency for acute neck pain patients
• Chiropractic utilization guidelines are available, but are only based on a consensus of opinion
3Palmer College of Chiropractic WestPalmer College of Chiropractic West
Neck pain–manipulation Cochrane Review Gross et al
• 33 trials regarding acute, subacute, and chronic mechanical neck pain – 42% were of high quality
• Involved single sessions of manipulation or multiple sessions of manipulation or mobilization over 3 to 11 weeks
• Multimodal manual therapy care including exercise was most beneficial
• Total visits were specified in study designs
4Palmer College of Chiropractic WestPalmer College of Chiropractic West
Purpose of this study
• To discover how doctors of chiropractic (DCs) manage patients with acute neck pain with regard to the total number of visits involved
• To find out if there were any apparent relationships between total visits and other variables, such as pain levels, etiology, age, gender, etc.
5Palmer College of Chiropractic WestPalmer College of Chiropractic West
Methods
• A two-part survey was administered to participating DCs and their patients who were seen for an episode of acute neck pain (retrospective)
• DCs collected information from patient files
• Patients responded to a telephone survey– Informed consent was obtained orally
6Palmer College of Chiropractic WestPalmer College of Chiropractic West
Results
• 115 patients were contacted and asked to participate in the survey
• 20 declined
• One case was not included because responses were provided by the mother of a child patient
• Ultimately, 94 acute neck pain patients participated
7Palmer College of Chiropractic WestPalmer College of Chiropractic West
Demographics
• 60 females (64%) and 34 males (36%)
• Mean age 39.6 years (SD = 15.7)
• 7 participating DCs– Primarily from the San Diego, CA area – 3 were from Idaho, Utah, or Arkansas
8Palmer College of Chiropractic WestPalmer College of Chiropractic West
0 10 20 30 40 50 60 70 80 90
Age
0
5
10
15
20
25
Obs
serv
atio
ns
9Palmer College of Chiropractic WestPalmer College of Chiropractic West
Visits
• The total number of visits provided to each patient ranged from 1 to 117
• The mean number of visits was 24.3 (SD = 21.16) – Females 24.5 (SD = 20.2) – Males 24.1 (SD = 23.0)
• Mean number of visits varied among DCs – Ranging from 5.5 (SD = 3.7) to 41.6 (SD =
25.0)
10Palmer College of Chiropractic WestPalmer College of Chiropractic West
Visits cont.
• Injury-related patients received more visits than non-injured– Mean 34.7 (SD = 21.1) visits for injured– Mean 10.1 (SD = 10.1) for non-injured
• Patients who were injured in motor vehicle crashes received the most visits– Mean 46 (SD = 19.1) visits
11Palmer College of Chiropractic WestPalmer College of Chiropractic West
The number of visits among patients was variable
Count Cumulative Percent
1-20 50 50 52.6
21-40 23 73 24.2
41-60 20 93 21.1
61-80 0 93 0.0
81-100 1 94 1.1
101-120 1 95 1.1
97.9% of the patients received 60 or less visits
12Palmer College of Chiropractic WestPalmer College of Chiropractic West
35%
18%
12%13% 13%
8%
0% 0%1%
0% 0%1%
0 10 20 30 40 50 60 70 80 90 100 110 120
Visits
0
5
10
15
20
25
30
35O
bse
rva
tion
s
13Palmer College of Chiropractic WestPalmer College of Chiropractic West
Variability of visits was related to associated trauma
Trauma No Trauma
Valid N 55 40
Mean total visits 34.7 10.1
Minimum 1 1
Maximum 117 57
Standard deviation 21.2 10.1
14Palmer College of Chiropractic WestPalmer College of Chiropractic West
N Y
Trauma
0
20
40
60
80
100
120V
isit
s
Point-biserial r = 0.58
15Palmer College of Chiropractic WestPalmer College of Chiropractic West
Weak correlations
• Initial pain levels did not appreciably influence the total number of visits – Although it was expected
• The level of patient satisfaction was not correlated to total visits
16Palmer College of Chiropractic WestPalmer College of Chiropractic West0 2 4 6 8 10
Initial Pain
0
20
40
60
80
100
120N
um
be
r o
f V
isit
s
Outlier
Extreme Studentized Deviate (ESD) z = 4.38, P < 0.05
Rho = 0.2 0.24 (without outlier)
17Palmer College of Chiropractic WestPalmer College of Chiropractic West
DissatisfiedSomewhat dissatisfied
Somewhat satisfiedSatisfied
Very Satisfied
Satisfaction
-20
0
20
40
60
80
100
120V
isit
s
Rho = -0.0951
18Palmer College of Chiropractic WestPalmer College of Chiropractic West
Weak correlations cont.
• Patients without a history of neck pain were seen more often than those with– Without history 26.1 (SD = 22.6)
• 25.0 (SD = 19.8) when 117 visit outlier is removed
– With history 19.9 (SD = 16.7)
19Palmer College of Chiropractic WestPalmer College of Chiropractic WestWithout With
Neck Pain History
0
20
40
60
80
100
120
Vis
its
20Palmer College of Chiropractic WestPalmer College of Chiropractic West
More vs. fewer visits
• Comparing the two DCs with the highest total visits with the two DCs with the lowest, several things were evident regarding patients who received fewer visits
1. They were more satisfied with their care
2. Their improvements with regard to pain levels were comparable to those with higher visits
21Palmer College of Chiropractic WestPalmer College of Chiropractic West
More vs. fewer visits cont.
3. They were more likely to choose chiropractic again in the future if they had a similar problem
4. They were much less likely to report continuing disability
• May be related to – A higher proportion of trauma cases among
DCs who provided more visits– Disability patients required more visits
22Palmer College of Chiropractic WestPalmer College of Chiropractic West
DC Number 1 2 3 4 5 6 7
Valid N 13 5 6 25 11 20 15
Visits - mean 31 37.6 11.5 41.6 5.5 22.6 6.6
Finished treatment % 85 60 17 88 55 60 40
Trauma % 100 100 67 72 36 35 27
Satisfaction 5.4 5.2 5.3 5.6 5.9 5.8 5.7
Pain after treatment 0.85 1.8 1.4 2.3 1.1 2.3 2.5
Likely to return % 69 80 50 88 100 95 100
5.541.6
23Palmer College of Chiropractic WestPalmer College of Chiropractic West
Conclusions
• There was wide divergence in the number of chiropractic visits provided to acute neck pain patients in this study
• Patient satisfaction and pain levels after care were similar between high and low total visit subgroups
24Palmer College of Chiropractic WestPalmer College of Chiropractic West
Further research is necessary
• To determine optimal total visits for acute neck pain patients with regard to:– Varying degrees of initial subjective and
objective findings– The presence of trauma and types of trauma– Demographic factors
• Involving more DCs• Much larger sample of patients• Prospective design