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A cross-sectional, anonymous, and voluntary survey was distributed to students attending the chiropractic program at University of Southern Denmark, in their 3rd to 5th academic year, and to recently graduated students who were enrolled in the obligatory 1-year internship program at either a primary or secondary care practice in Denmark.
Students were informed of the study by email (via the internal university information platform) with two later reminders (8th and 22nd of October 2019). Furthermore, information was presented in-class by a lecturer or researcher involved in the study. Students were allowed time to complete the survey during regular class. The first page of the survey consisted of a brief explanation of the project identical to that of the private college study (Supplementary File 1).
Clinical interns were informed about the study during a meeting pre-scheduled as part of the internship program (Oct. 27th, 2019). Time was allowed initially in the meeting to complete the survey. No reminders were sent.
It took approximately 10 minutes to complete the survey which was conducted using SurveyXact (11), and all data were collected anonymously online. No attempts were made to identify any of the respondents on the basis of their demographic data or replies. No ethics permission is necessary to conduct an anonymous survey in Denmark (12).
Survey
The survey instrument consisted of two parts:
Conservatism
The first part was a chiropractic conservatism questionnaire with six statements regarding chiropractic spinal ‘adjustments’ and four statements regarding spinal ‘subluxations’. These were Danish translations of the previously published questionnaire used in the private college study (4) (Table 1). Responses were collected using 5-point Likert scales anchored with ‘Definitely not’/’Strongly disagree’ to ‘Yes, definitely’/’Strongly agree’ (Supplementary file 2).
Table 1. Ten statements used to determine the degree of conservatism
Items regarding spinal manipulation/adjustments
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Items regarding spinal dysfunctions/subluxations
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Adjustments can prevent disease in general
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Subluxations are the cause of all disease
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Adjustments can help the immune system
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Subluxations cause short-circuits of the nervous system
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Adjustments can improve the health of infants
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Subluxations can have a negative effect on the capacity of the nervous system to provide energy to tissues and organs
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Adjustments can help the body function at 100% of its capacity
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It is possible to detect subluxations before symptoms appear
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Adjustments can prevent degeneration of the spine
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It is appropriate for every person to receive chiropractic adjustments for their entire life
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Clinical decision-making
The survey further included 9 clinical cases concerning I) low back pain (n=4), II) neck pain (n=3), and III) primary prevention in a child (n=2). The full questionnaire is provided in Supplementary File 2.
These three sets of clinical cases were used to assess students’ ability to detect contra-indications, non-indications, and indications for spinal manipulation. See Box 1
BOX 1: Definitions of the different indications used in a survey on chiropractic students attending the University of Southern Denmark
Contra-indication: Cases where spinal manipulation would be associated with a non-trivial risk of complications e.g. manipulation of spinal fracture.
Non-indication: Cases where spinal manipulation is not contra-indicated, but where no evidence-based clinical rationale for offering the treatment is present e.g. manipulation offered as treatment of asthma or as prevention for infection.
Indication: Cases where spinal manipulation is not contra-indicated, and musculoskeletal symptoms are present with clinical findings providing an evidence-based rationale for spinal manipulation e.g. spinal pain syndrome with biomechanical dysfunction.
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Translation process and pilot testing
The survey was translated using a modified cross-cultural adaptation technique (13). A fluent English and Danish speaker (SON) translated the original English version to Danish, and afterwards another fluent English and Danish speaker (HHL) translated it back to English. Finally, a consensus meeting between SON, HHL and CGN was held, and the final Danish version was agreed upon. The survey was pilot tested by four chiropractors who recently completed their internship. This did not generate any changes to the survey.
I) Low back pain questionnaire
A subset of four questions were adopted from a previously published and validated questionnaire (14–16) related to a case of a 40-year old male with local LBP and no additional musculoskeletal complaints.
In the four questions, the case develops in four different ways: i) no prior LBP and complete remission after two sessions, ii) previous recurrent LBP and complete remission after two weeks, iii) previously one year of intermittent LBP and gradual worsening over six sessions, iv) previously one year of intermittent LBP, minor (clinically irrelevant) improvement after six sessions and possible undiagnosed underlying depression.
The respondents were asked to choose one of seven possible strategies for each of the four case-developments a) second opinion, b) additional treatment, c) ‘quick-fix’, d) try again, e) symptom guided maintenance care (patient administered), f) clinical guided maintenance care (clinician administered), and g) finally, students could reply other and add an answer in the comment section. Cases iii) and iv) were considered to be non-indicated for continued care because iii) was a case where the patient does not respond to spinal manipulation but gradually worsens and iv) indicates a non-mechanical LBP pattern most likely due to a non-musculoskeletal condition (depression).
II) Neck pain questionnaire
A subset of three questions were adopted from a questionnaire previously used in a study of French chiropractors (17). The case describes a 28-year old male tennis player with neck pain and antalgic head position. The case develops in the following three ways: i) Simple mechanical, local neck pain, ii) simple mechanical neck pain with radiation to the trapezius muscle, and iii) development of signs of an upper motor lesion. The first two cases were considered indications to treatment, whereas the third was an obvious contra-indication.
III) Primary prevention in a child
We included two additional questions adopted from the previous study of the private college (8) regarding primary prevention. The first case concerns the mother of a 5-year old child with no prior spinal pain, who consults a chiropractor, asking if the chiropractor would be able to treat the child preventively to avoid future spinal pain. The second case describes the mother of a 5-year old child with a long family history of multiple comorbidity, breast cancer, diabetes etc., who asks if the chiropractor would be able to treat the child preventively to avoid the onset of diseases in the future. Both cases were obvious non-indications to chiropractic treatment.
Interpretation of “other”
For the clinical cases, the students also had the possibility to answer other and write a comment. All comments were read thoroughly and independently by two authors (CGN and SON). When consensus could be reached the ‘other’ answers were re-classified into one of the fixed answer possibilities or left under ‘other’. If consensus could not be achieved, a third author (HHL) arbitrated the decision.
Variables of interest
Dependent variables (clinical appropriateness)
Answers to the nine clinical cases were dichotomized into an ‘appropriate’ answer (0) and an ‘inappropriate’ answer (1) as defined in the primary publication (18). The rationale for these is described in Supplementary File 3.
Independent variable (chiropractic conservatism)
Each answer to the 10 questions concerning chiropractic conservatism was dichotomized into an ‘appropriate’ answer [0] and an ‘inappropriate’ answer [1], using the same classification as that used in the previous study on this topic (8). A total sum of inappropriate answers was calculated and used as ‘the conservatism score’ [0-10]. This score was then further categorized into four groups: group 1 with scores of 0-2, group 2 including scores of 3-5, group 3 for scores of 6-7, and group 4 included scores of 8-10, i.e. the same categorization as previously reported (8).
In addition, sex, age, and academic year were included as descriptive variables.
Statistics
Descriptive data for age is reported as the mean and standard deviation. All categorical data are reported as count, frequency and binary 95% confidence intervals. The proportion of ‘appropriate’ answers to the clinical questions is visualized as bar graphs for each question per academic year, including error bars representing 95% confidence interval.
The associations between the dependent variables (clinical appropriateness) and the independent variable (the conservatism score) were tested for statistical significance using logistic binomial regression, both unadjusted and adjusted for sex and academic year. All associations are presented as odds-ratios with 95% confidence intervals. Non-overlapping of confidence intervals would determine if differences are statistically significant.
Data analyses and data wrangling of the Danish study were performed using the tidyverse (19) in R (20) (Linux, v. 3.6.0 with R-studio v. 1.1.456). The exactci package (21)was used to calculate 95% confidence intervals (CI).