A feasibility study assessing a program of care for chiropractors managing spinal pain in Canadian Armed Forces personnel

Abstract

Introduction:

Chronic back and lower and upper limb disorders are common and responsible for 42% of medical releases from the Canadian Armed Forces (CAF). Chiropractors care for CAF personnel off base, but collaboration with Canadian Forces Health Services (CFHS) varies among Canadian Forces Bases (CFBs). Developing a program of care (PoC) could address such variation. This study aimed to develop and assess the feasibility of implementing a PoC to improve chiropractors’ communication with CFHS and delivery of spine care to active duty CAF personnel.

Methods:

This mixed-methods feasibility study involved two CFBs. Eligible participants included Medavie Blue Cross registered chiropractors, active duty CAF members with spinal pain, and CFHS personnel. Feasibility metrics included participation rates, attendance at meetings, completeness of clinical reports and patient outcome questionnaires, adherence to guidelines, and participants’ experiences with study protocols and care. Data were analyzed descriptively and thematically.

Results:

Participants were 55% (11/20) of invited chiropractors and 85% (22/26) of referred CAF and invited CFHS personnel. All chiropractors and CFHS personnel attended on-base meetings. Training sessions, meetings, and educational materials enhanced understanding of military culture and treatment expectations. 98% of clinical reports and outcome questionnaires were completed, and practice guidelines were followed. Participants suggested that communication between chiropractors and CFHS personnel improved compared with prior experience.

Discussion:

Implementing a PoC that enhances communication with CFHS personnel and delivers evidence-based spine care to CAF members is feasible. Future work is needed to determine whether such care improves outcomes among CAF members with spinal pain.

Lay Summary

Spinal pain is responsible for a large proportion of pain and disability in the Canadian Armed Forces (CAF). The authors developed and implemented a program of care (PoC) that included communication strategies and care pathways supporting chiropractic care for CAF personnel with spine-related problems. The authors tested the feasibility of implementing the PoC on two select CAF bases and found that it was feasible to implement, with a high rate of completion of patient outcomes, adherence to clinical pathways, and enhanced interprofessional communication and reporting. Participants reported satisfaction with the program. Successful implementation of a PoC could provide guidance and support for interprofessional collaborative care for CAF personnel with spine-related pain.

Introduction

Musculoskeletal (MSK) disorders are a leading cause of morbidity and disability that contribute a significant burden to the operational readiness of the Canadian Armed Forces (CAF).¹ MSK disorders of the back, lower limbs, and upper limbs are the most common chronic health conditions reported by CAF members and are responsible for 42% of all medical releases.^1–3 The CAF has recommended prioritizing research and increasing clinical resources to reduce the burden of MSK disorders.²

Community-based chiropractic services are available off base for CAF members upon direct referral from a Canadian Forces Health Services (CFHS) provider, although little is known about the outcomes of such care.⁴ In contrast, on-site chiropractic services are provided at U.S. military treatment facilities. A recent randomized controlled trial involving active duty U.S. military members with back pain demonstrated that providing chiropractic and usual medical care improved pain, disability, and satisfaction with outcomes compared with usual medical care alone.⁵

In Canada, there is a paucity of research assessing chiropractic services in the CAF. A case series of 69 CAF members reported high satisfaction with care received from on-base chiropractors.⁶ Recently, a qualitative study identified opportunities and challenges regarding the integration of chiropractic services within the CAF.⁷ Challenges identified included chiropractors’ lack of understanding of CAF culture and CFHS expectations, inconsistent referral procedures and variation among Canadian Forces Bases (CFBs), lack of standardized clinical reporting, limited to no follow-up communication with on-base personnel, the perception of duplicated scope of practice between chiropractors and physiotherapists, and concerns raised by CFHS participants related to the variable and non-evidence-based care delivered by some chiropractors. Opportunities included benefits of varying treatment approaches used by different providers, adoption of current, best-evidence, patient-centred guidelines, structured strategies to improve communication, understanding of treatment expectations for active duty military members, and co-location to improve interprofessional relationships.

In advance of an implementation study, the authors developed a standardized program of care (PoC) for community-based, off-site chiropractors managing care for CAF personnel with spinal pain conditions. The PoC was designed to address previously identified concerns and opportunities, particularly those related to understanding CAF culture and CFHS expectations, improving communication with CFHS personnel, and ensuring consistency in delivering evidence-based spine care. Specifically, this study aimed to evaluate the feasibility of implementing the PoC by assessing participation rates of chiropractors and CAF patients, attendance at on-base meetings by chiropractors, completeness of reports from chiropractors, and completeness of patient-specific questionnaires from CAF patients. The study also evaluated adherence to practice guidelines by chiropractors, patients’ assessment of relational care (i.e., the quality of the patient-provider relationship and communication), and the quality of care. Furthermore, the authors gathered feedback on experiences with study protocols and care delivery from all participants — chiropractors, CAF patients, and CFHS personnel.

Methods

Study design

The authors conducted a feasibility study using a sequential mixed-methods approach. The adaptive nature of a feasibility study permits the modification and optimization of study components and procedures to facilitate the study’s objectives.⁸ Feasibility metrics determine whether an intervention or PoC can be implemented, thus paving the way for future robust evaluation of clinical outcomes in interventional studies.⁸ The study was conducted between April and July 2019 at the eastern site and between November 2019 and March 2020 at the western site; however, the latter was interrupted by the COVID-19 pandemic lockdown. The study was reported according to the Consolidated Standards of Reporting Trials (CONSORT) guidelines for reporting non-randomized pilot and feasibility studies.⁹

Procedure

The authors developed and assessed the feasibility of implementing the PoC guided by Donabedian’s conceptual quality framework,¹⁰ in which structure describes the setting, material and human resources, and organizational configuration, process describes the processes and delivery of health care, and outcomes include the results of care on patients’ health status and satisfaction.

Structure

Two CFBs were selected in consultation with the CFHS study advisor (practice leader). Selection was based on interest in participating, prior use of chiropractic services, on-base resources, and location. Chiropractors were purposefully recruited with input from the care delivery units and CFHS advisor at the selected CFBs. Eligible chiropractors were registered with Medavie Blue Cross (third-party insurance provider) and located near the participating CFBs. CAF members were eligible to participate if they were active duty, spoke English, and were referred to chiropractic care for spinal pain (neck, thoracic, or low back pain). Spinal pain was defined as per the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders and the European Guidelines for Prevention of Low Back Pain.^11,12 CAF members were excluded if they had spinal pain of pathological origin (e.g., tumor, infection, fracture, systemic condition) or were non-active duty personnel (e.g., Veterans). CFHS personnel (physicians, physiotherapists, nurse practitioners) at the two CFBs were invited to participate if they were directly involved in managing CAF members with spinal pain.

Chiropractors were organized at each site and guided by the principles of Practice-Based Research Networks (PBRNs) to facilitate the implementation of the PoC. A PBRN consists of health care providers and researchers united by a clear vision, with the intent to assist in coordinated research and to implement existing evidence-based knowledge into practice.^13,14 PBRNs facilitate this by developing professional partnerships among local leaders, researchers, clinicians, and support personnel.^13–16 These partnerships are maintained through an infrastructure that facilitates effective communication and knowledge transfer between participants.^13,14,16

The following feasibility metrics were used to assess the structure of the PoC: participation rates (number participating/number individuals invited) of chiropractors, CFHS providers, and CAF members, participation rate in the study and end-of-study interviews, access to web-based materials (number), and exploration of participants’ experiences and perceptions of their study participation, support, and education (interviews and focus group).

Process

Four process modules were created with input from the CFHS advisor and informed by prior work.⁷ The modules provided information to participating chiropractors and CFHS personnel, including 1) training manuals outlining study components, procedures, and participant expectations and education about the unique CAF culture, with specific reference to care delivery to ensure CAF members are ready for deployment (operationally ready), 2) standardized tools for clinical communication and reporting requirements from chiropractors to the CFHS (i.e., initial clinical assessment, care progress, and discharge reports; see example in Appendix 1), 3) patient-specific data, including patient demographics and common condition questionnaires and their collection and scoring protocols (Table 1), and 4) specific evidence-based clinical pathways for managing CAF members with spinal pain conditions.^17–19 The modules were collated and made available in hard copy and on a dedicated study website. Additionally, in-person meetings were held on each CFB before the study began to formally introduce the participating chiropractors and CFHS personnel and review study procedures and materials.

Table 1.

Data collected from CAF participants and timing

Data collection tools*	Pre-intervention	Mid-intervention†	Post-intervention
Demographic questions	✓
Pain intensity: NRS	✓	✓	✓
Duty status	✓	✓	✓
Recovery expectations	✓
Roland Morris Disability Questionnaire (if applicable)	✓	✓	✓
Neck Disability Index (if applicable)	✓	✓	✓
Patient-reported outcome: MYMOP2	✓
Patient-reported outcome: MYMOP2 follow-up		✓	✓
Recovery: GPE Scale	✓	✓	✓
Quality of life: EQ-5D-5L	✓		✓
Quality of care: PCAS			✓
Health resource utilization and cost diary			✓
Clinician assessment and physical examination findings, diagnosis, recommended plan of management, prognosis	✓	✓	✓

* Items 1–12 are patient-reported questionnaires. Estimated patient time required to complete questionnaires at each time point is 15–20 min.

^† Mid-intervention data collected only if requesting continued care (e.g., approval for more visits beyond maximum number allowed).

CAF = Canadian Armed Forces, NRS = numeric rating scale, MYMOP2 = Measure Yourself Medical Outcome Profile 2, GPE = Global Perceived Effect, EQ-5D-5L = five-level EuroQoL, PCAS = Primary Care Assessment Survey,

Feasibility metrics for process-related items included rates of all study participation and on-base meeting attendance recorded by the study coordinators, rate of completeness of standardized reporting tools required for clinical documentation, rate of adherence to practice guidelines determined by contrasting the reported plan of management with the provided clinical care pathways, and exploration of participants’ experiences and perceptions of PoC processes.

Outcomes

Common condition questionnaires and their scoring protocols were included to track outcomes and quality of care, as well as demographic and duty status data (Table 1). The authors selected a reliable and valid pain numeric scale and neck and back disability questionnaires (Neck Disability Index and Roland Morris Disability Questionnaire, respectively) to assess participants’ average pain intensity and related disability.^20–22 On the basis of input from the CFHS advisor, the Measure Yourself Medical Outcome Profile 2 (MYMOP2),²³ a patient-centred instrument to measure the impact of patient-identified conditions, was included, as was a brief description of how to use the it. The authors learned, however, that describing its use to eastern Canadian chiropractors was insufficient given their lack of familiarity with its application. Thus, for western Canadian chiropractors, an explanation and illustration of how to engage patients in completing the MYMOP2 was included. Quality of life was assessed using the five-level EuroQoL (EQ-5D-5L).²⁴ Recovery was assessed from two perspectives: at initial visits using the expectation of recovery scale and over time using the Global Perceived Effect Scale to quantify an individual’s improvement or deterioration.^25,26 The Primary Care Assessment Survey (PCAS) was used to assess patients’ perceptions of the chiropractor-patient relationship by measuring levels of communication, trust, knowledge of the patient’s health and personal life, and comfort with the encounter and as a proxy for quality of, and satisfaction with, care.^27–30 Finally, a health resource utilization and cost diary was used to measure CAF participants’ health care use and cost during chiropractic care delivery — a reliable means of accurately determining resource use and cost. Feasibility metrics for outcomes of the PoC included rate of completion of each questionnaire at each appropriate time of care delivery. Additionally, the authors explored participants’ experiences with use and completion of outcomes.

Data analysis

Quantitative data were descriptively analyzed using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. To explore participants’ experiences with PoC structure, processes, and outcomes, focus groups and semi-structured individual interviews were conducted by four experienced authors, unfamiliar to participants, virtually, in person, or by telephone. Individual and focus group interview guides were developed on the basis of previous work and the study framework. Qualitative data from the individual interviews, which ranged in length from 18 to 57 minutes, and a 90-minute focus group interview, were audio recorded and transcribed verbatim. Transcripts were reviewed, decontextualized, and recontextualized, and codes were created and organized into representative subcategories. The subcategories were then grouped into main categories and organized into emergent themes. Transcripts were independently reviewed and coded by three authors, who met to discuss and reach consensus on the coding and structure of the final categories and themes.³¹ Such triangulation increases the validity and trustworthiness of results.³¹ Participants, except those in the focus group, were provided an opportunity to review their transcripts and edit responses. Selective verbatim quotes were used to highlight categories. Finally, the quantitative and qualitative findings were integrated into the results and discussion.

Ethical approval

Ethical approval was granted by the Research Ethics Boards of Ontario Tech University and Canadian Memorial Chiropractic College. Agreement to conduct the study was provided by Director Medical Policy, Health Services Group Headquarters, CAF.

Results

Recruitment and participation

Two CFBs participated, one located in eastern Canada and one in western Canada. Of 20 invited chiropractors, 11 (n = 4, eastern Canada, n = 7, western Canada; 55%) participated in the study. Of these, 9 were invited to participate in the end-of-study interviews, and 8 (89%) agreed (Table 2). Chiropractors declined to participate in the study for personal reasons (n = 6), work demands (n = 1), changing practice location (n = 1), and other (n = 1). One eastern Canadian chiropractor (1/4; 25%) dropped out because of a lack of CAF member referrals, and one eastern chiropractor received and provided care to all CAF participant referrals.

Table 2.

Chiropractor participation in selected study procedures and processes

Study procedures and processes	Western Canada	Eastern Canada
Invited to participate*	8	12
Agreed to participate, n (%)	7 (88)	4 (33)
No. of meetings (average % attendance)†	3 (62)	4 (83)
End-of-study interview‡	5 (100)	3 (75)
Website utilization§	12	3
Dropped out	0	1 (25)

* Recruited to attend initial on-base meeting before agreeing to participate.

^† Average % attendance across all meetings throughout study duration.

^‡Number invited and % participating in end-of-study interviews.

^§ Frequency participating chiropractors accessed the website during the data collection period.

Chiropractors who participated credited a sense of professional duty to contribute to research, the promotion of evidence-based care for MSK disorders, and a desire to enhance the acceptance, integration, and availability of chiropractic services within the CAF (Table 3, quote IA1). However, participants expressed concern with the anticipated study workload (Table 3, quote IA2).

Table 3.

Example quotes from participant interviews

Theme	Example quotes from participant interviews
I. Study recruitment
A. Chiropractor recruitment	“I was excited to participate really. I think that research is an important part of our profession, and I think specifically for me, I mean any opportunity to improve, whether it be communication, which was really the goal of this study I guess, or any type of relationship with the base which is a huge part of our community and a huge part of my practice.” (chiropractor, E6) “I knew a few other practitioners in town that had turned [the study] down, and I was quite shocked and quite surprised. I think they had the thought that it was going to be too all-encompassing, too much work when we are all quite busy with families and everything.” (chiropractor, W1)
B. CAF recruitment	“We missed our first few opportunities … and you guys gave us advice that then really worked… our track record at that appointment was 0% so we might not have had any participants for you guys if we had kept doing it the way we did so obviously that was valuable.” (chiropractor, E6) “I was certainly involved in some of the meetings that occurred with our local chiropractors in the beginning and was available to talk to any of them if they had any questions during it. I certainly appreciated the new forms that were produced through this program, and it helped guide things a little bit better and I think everyone has a better understanding of what everyone’s role is now.” (CFHS1)
II. Study retention & participation	“Being able to work closely with my colleagues here in town as part of a research team was really great and, you know, seeing the support that we got from [research team] and everybody was amazing. They really made it so easy for us to participate so I really have nothing but amazing things to say.” (chiropractor, W2) “[The meetings] were pretty good and I think they were necessary. I think you kind of have to have that meet-up point just to say hey how is it going, do you have any questions, concerns? Especially in the environment if you are not expecting a lot of referrals because again, I dove in pretty deep and read everything at the beginning but if you don’t get a referral for the first three or four weeks sometimes you get a little rusty on it.” (chiropractor, E5)
III. Framework
A. On-base meeting, education and training	“It just never even crossed my mind that I was dealing with a completely different world with different objectives and goals and procedures, and so once I was a little bit more enlightened around that it changed drastically how I communicated with the base, and then the form that was provided to us to fill out just helped to really crystallize that communication into a very simple and easy and succinct format.” (chiropractor, W2) “I certainly really enjoyed getting to know the chiropractors on a face-to-face basis and having conversations with them … I think my relationship with the practitioners in town was much improved by [the study] and everyone then was on the same page and understood okay this is what we are working within let’s try and work together for the better of the patient. So that I thought was great.” (CFHS1) “Being on base and meeting the MDs, the surgeons, the ortho, the nurse practitioners. [XX] had been referring to me for the last 4 years but I’ve never met her. So yeah, it was just putting faces to names and you know saying okay that’s you, nice to meet you [XX] [laugh]. It’s about time we met as we have been corresponding quite a bit. I found that after I met them it just kind of, the communication was better. (chiropractor, W3)
B. Disruption to care delivery	“He is a PTSD patient and he was given the opportunity to go to a facility that was overnight and away for a few months type of thing so he wasn’t going to be able to finish.” (chiropractor, E6)
C. Data collection package	“I didn’t have any issues, I mean the only thing that was really new was having to fill out those MYMOP questionnaires for the patient but honestly that took like three minutes, it was not that big of a deal. We knew we already had to fill out, it actually streamlined, I would say, my communications with the base, made it easier and faster to fill that out and to complete that task. So, you know I think my experience was nothing but positive, and I didn’t really have any issues with any of the of those any aspects of the data collection package at all.” (chiropractor, W2) “The paperwork was fairly easy to fill out, and it didn’t take a lot of time and just happened while I was actually waiting for my appointment.” (CAF member, F6)
D. MYMOP2	“Like this [MYMOP2 patient-specific outcome measure], choose one or two symptoms physical or mental, and I was grasping, well, like, what would my mental health have to do with my back?” (CAF member, F2) “We were reminded lots as well. Like [researcher] would send out emails and just say, hey, just a reminder that you need to get them to fill out the MYMOP. All the communications were helpful. I also have an amazing front desk woman and she would tell me when I needed to do something.” (chiropractor, W3)
E. Reports to CFHS	“The [report] has never been my favourite thing, which I have expressed to you guys before. I always find that any time you are boxed into a small area … it limits me in some ways, but I am always sort of more about the narrative.” (chiropractor, E6) “Then the form that was provided to us to fill out just helped to really crystallize that communication into a very simple and easy and succinct format. So, I am going to definitely keep using that form when I communicate.” (chiropractor, W2) “Yes, I would say the reports were useful … they were more congruent with the reason the person was referred than they had been in the past … in the past on occasion … we would send somebody off for, you know, problem A and [the report] might come back saying that is great but now we are working on some other body part and not even looking like they addressed problem A.” (CFHS2)

E = eastern Canada, W = western Canada, CAF = Canadian Armed Forces, CFHS = Canadian Forces Health Services, PBRN = Practice-Based Research Network, PTSD = posttraumatic stress disorder, MYMOP2 = Measure Yourself Medical Outcome Profile 2.

Of the CAF members referred to participating chiropractors, 55% (5/9) in eastern Canada agreed to participate, and 100% (17/17) agreed to participate in western Canada. Reasons for declining were ineligibility because of non-spinal pain (n = 1), time constraints (n = 1), discharge from the military (n = 1), and unknown (n = 1). Ten CAF members were invited to participate in the end-of-study individual interviews (n = 8) and one focus group (n = 2) in eastern Canada.

Feedback from chiropractors noted that low CAF member referrals, CAF members’ time constraints, and scheduling conflicts were barriers to initial CAF recruitment attempts in eastern Canada. As a result of early study feedback from chiropractic office staff, the research team advised staff to recruit CAF participants in office, rather than over the phone, and to schedule longer initial in-office appointments. Chiropractors reported that this change in process improved CAF member recruitment success (Table 3, quote IB1).

All (100%) invited CFHS providers participated in the study and end-of-study individual interviews. One was from the eastern CFB and four were from the western CFB (Table 3, quote IB2).

All participating chiropractors and invited CFHS personnel were present during the initial on-site meeting. Eastern and western participating chiropractors accessed the study website 3 and 12 times, respectively; however, they considered it complementary to the hard-copy study manual. It is important to note that, for all chiropractors, the on-base meeting was the first time they received any type of education about CFHS communication requirements and health care delivery expectations. This ground-breaking meeting reinforced the care expectations (Table 3, quote IIIA1) and provided CFHS personnel with an opportunity to meet the chiropractors (Table 3, quote IIIA2). Feedback regarding the two in-clinic meetings and open email communication with the research team suggested that this provided sufficient support and motivation for chiropractors to continue participating in the study despite few CAF referrals, particularly at the eastern location (Table 3, quotes II1 and II2).

Collection and completion of reports

The data collection packages for all CAF participants were returned to the research team. On average, 50%–100% of individual reports were completed and delivered (Table 4). One western chiropractor did not return three mid-intervention and post-intervention discharge reports to the research team, and whether these reports were delivered to the CFHS is unknown. Reasons for failed delivery or incompleteness of required documentation by chiropractors included withdrawal from care because of COVID-19 pandemic restrictions (n = 2), elapsed data collection period (n = 6), disruption of care by CAF participants because of other health complaints or duty obligations (n = 2), discharge from care before reaching mid-intervention criteria (n = 2), and delayed treatment extension approval (n = 1).

Table 4.

Report completeness and delivery

Reports to CFHS	n (%)
	Initial assessment report		Mid-intervention report		Post-intervention or discharge report
	Western	Eastern	Western	Eastern	Western	Eastern
Eligible reports delivered	17 (100)	5 (100)	11 (79)	2 (50)	8 (73)	1 (50)
Reports with missing data	0	0	0	1 (50)	0	1 (50)
Reports delivered at appropriate interval	16 (94)	5 (100)	6 (55)	2 (100)	8 (100)	1 (100)

CFHS = Canadian Forces Health Services.

Chiropractors reported mixed feelings about the implementation and use of the initial patient assessment report completed by chiropractors and sent to the CFHS. Most chiropractors saw the benefit of the succinctness and ease of use of the templated reports (Table 3, quote IIIE2). However, some chiropractors cited prior practice habits as a deterrent to their long-term sustained application (Table 3, quote IIIE1). All CFHS members found that the reports were beneficial in helping to clarify CAF member limitations and treatment outcomes, which facilitated treatment extensions and care delivery for CAF members (Table 3, quote IIIE3).

The majority of chiropractors adhered to the care pathway’s recommended interventions for the majority of patient treatments. Minor deviations from the recommended interventions included the use of soft tissue therapy in a number of care plans and one instance of the application of laser therapy for acute low back pain. Whether education or reassurance was provided to CAF participants was unclear because this was not specified in either the completed treatment plans or the reports.

All chiropractors felt that the educational materials and on-base meeting greatly enhanced their understanding of military health care culture, CAF members’ return-to-duty health care goals, and communication expectations with the CFHS (Table 3, quote IIIA1). Both chiropractors and CFHS personnel felt the level of interprofessional collaboration improved because of interpersonal familiarity and relationships developed after the on-base meeting (Table 3, quotes IIIA2 and IIIA3). For example, during the study period, CFHS providers and chiropractors felt more comfortable with direct email and telephone communication, which was a rare occurrence before the introduction of the PoC (Table 3, quote IIIA3). At the western Canada site, the CFHS held a second on-base meeting for participating community-based chiropractors and other community-based health care providers to provide additional education about CFHS health care, highlighting the perceived value of the educational session with off-base providers.

Completion of patient-reported outcome measures

Of the 22 initial reports submitted, total completed outcomes ranged between 96.1% and 99.7% (Table 5). Of the outcomes required to be completed, the follow-up MYMOP2 had the most incomplete items. All CAF participants recorded improved clinical outcome scores (Table 6). On the basis of PCAS scores, CAF members perceived the chiropractor had a lower level of knowledge about them but reported higher scores for thoroughness of examination, communication, interpersonal treatment, and trust with their chiropractors, suggesting satisfaction with care (Table 6).

Table 5.

Completeness of patient information and outcomes

	n (%)
	Pre-intervention		Mid-intervention*		Post-intervention
Patient outcome (total no. of items)	Western† (n = 17)	Eastern† (n = 5)	Western† (n = 13)	Eastern† (n = 2)	Western† (n = 16)	Eastern† (n = 1)
Demographic characteristics (18)	302 (98.7)	89 (98.9)	N/A	N/A	N/A	N/A
Pain intensity (NRS) (1)	17 (100)	5 (100)	13 (100)	3 (100)	16 (100)	1 (100)
Duty status (1)	17 (100)	5 (100)	12/13 (92.3)	3 (100)	16 (100)	1 (100)
Recovery expectations (1)	17 (100)	5 (100)	N/A	N/A	N/A	N/A
RMDQ (24)	408 (100)	120 (100)	311 (99.7)	72 (100)	383 (99.7)	24 (100)
NDI (10)	170 (100)	50 (100)	130 (100)	30 (100)	160 (100)	N/C
MYMOP2 (9)	153 (100)	45 (100)	N/A	N/A	N/A	N/A
MYMOP2 follow-up (6)	N/A	N/A	75 (96.2)	13 (72.2)	86 (89.6)	4 (66.7)
GPE (1)	16 (94.1)	5 (100)	13 (100)	3 (100)	16 (100)	1 (100)
EQ-5D-5L (6)	101 (99)	30 (100)	N/A	N/A	95 (99)	6 (100)
PCAS (69)	N/A	N/A	N/A	N/A	1104 (100)	69 (100)
Health resource utilization and cost diary (18)	N/A	N/A	N/A	N/A	264 (91.7)	18 (100)
Total outcomesc	1201 (99.5)	354 (99.7)	554 (99.1)	124 (96.1)	2140 (98.3)	124 (98.4)

* Mid-intervention data collected only if requesting continued care;

^c: n = total number of outcome items completed for each site.

^† n = total number of outcome items completed/total number of items (variable items × participants).

na = outcome not collected at the specified intervention stage, NRS = numeric rating scale, RMDQ = Rolland Morris Disability Questionnaire, NDI = Neck Disability Index, MYMOP2 = Measure Yourself Medical Outcome Profile 2, GPE = Global Perceived Effect Scale, EQ-5D-5L = EuroQuol 5D-5L, PCAS = Primary Care Assessment Survey

Table 6.

Patient-reported outcome scores by location and intervention period

Patient-reported measure	Mean (SD)
	Pre-intervention		Mid-intervention		Post-intervention*
	Eastern (n = 5)	Western (n = 17)	Eastern (n = 2)	Western (n = 13)	Eastern (n = 1)	Western (n = 16)
Pain intensity (NRS)	7.0 (1.4)	5.4 (2.0)	3.5 (0.7)	3.7 (1.7)	3.0 (1.9)
Recovery (GPE)	0.4 (2.2)	0.0 (2.1)	2.5 (0.7)	1.9 (1.5)	2.5 (1.3)
Recovery expectations†	6.6 (3.4)	3.4 (3.4)	N/A	N/A	N/A
RMDQ	9.8 (4.5)	5.2 (4.1)	5.0 (1.4)	4.1 (5.1)	3.0 (4.8)
Neck Disability Index	19.0 (4.2)	9.7 (5.0)	12.0 (1.3)	7.9 (6.2)	5.0 (4.1)
MYMOP2: summary score	3.5 (1.2)	3.2 (1.4)	3.4 (1.0)	2.4 (1.1)	1.7 (1.0)
EQ-5D-5L
Mobility	2.6 (1.1)	1.7 (0.9)	N/A		1.0 (0.7)
Self-Care	1.6 (0.5)	1.2 (0.6)	N/A		1.0 (0.2)
Usual Activities	3.0 (1.2)	2.0 (1.1)	N/A		2.0 (0.9)
Pain or Discomfort	2.2 (0.8)	2.6 (0.6)	N/A		2.0 (0.5)
Anxiety or Depression	3.2 (0.4)	1.7 (0.8)	N/A		1.0 (0.4)
EuroQoL: HVAS, mean % (SD)	47 (20)	73 (12.7)	N/A		81 (14.6)
PCAS (n = 8)
Financial Access	N/A		N/A		72.0 (17.89)
Organizational Access	N/A		N/A		84.25 (13.16)
Knowledge of Patient	N/A		N/A		69.88 (17.56)
Thoroughness of Exam	N/A		N/A		97.50 (7.07)
Communication	N/A		N/A		93.75 (5.47)
Interpersonal Trust	N/A		N/A		98.50 (2.11)
Trust in Chiropractor	N/A		N/A		74.38 (5.27)

* Eastern and Western scores combined.

^† Score ranges from 0 to 10, with 10 being very likely.

NRS = numeric rating scale (score range 0–10, where 10 = as bad as could be), GPE = Global Perceived Effect Scale (score range −5 to 5, where 5 = completely recovered), RMDQ = Rolland Morris Disability Questionnaire (score range 0–24, higher score = greater disability), MYMOP2 = Measure Yourself Medical Outcome Profile 2 (mean of all completed individual scores, range 0–6 per item), EQ-5D-5L = EuroQoL 5D 5L (score range 1–5, lower scores = greater quality of life), N/A = not applicable at the intervention interval, EuroQoL HVAS = Health Visual Analog Scale (score range 0–100, higher scores denote greater perceived health), PCAS = Primary Care Assessment Survey (scores transformed out of 100, scale range 0–100, with higher scores being more favorable).

Disruptions to care delivery at both study locations because of CAF member duty re-assignments, COVID-19 pandemic restrictions, or other health care obligations resulted in delays in the timely collection of patient-reported outcomes and the delivery of reports (Table 3, quote IIIB1). Some chiropractors found the outcomes package for CAF participants cumbersome, and others found them helpful in completing reports to the CFHS. CAF members did not report concerns with the length or application of the outcome measures (Table 3, quote IIIC2). Overall, the outcome measures were considered appropriate and not disruptive to clinical practice routines (Table 3, quote IIIC1). The MYMOP2 outcome measure had the most incomplete items, which may be explained by comments from some eastern CAF participants who felt that selecting their own health concerns was confusing and preferred the more straightforward check-box format of other outcome measures (Table 3, quote IIID1). However, western participants, who were provided additional training based on lessons learned from eastern chiropractors about the completion and relevance of the MYMOP2, found it helpful and informative (Table 3, quote IIID2).

Discussion

To the authors’ knowledge, this is the first study to develop and assess the feasibility of implementing a PoC for chiropractors managing CAF members with spinal pain conditions. The authors found that developing and implementing a PoC, guided by PBRN principles, was feasible, based on the stated structure and process metrics. Findings align with literature on PBRNs, suggesting that clinicians who have strong beliefs and interests in research are more likely to agree to participate in studies, whereas a lack of clinician time, training, and support staff fatigue can limit participation.^15,32,33 Structuring the organization of health care providers within a PBRN framework is feasible and can help address barriers to and facilitators of participation in studies.

This study found that CAF member recruitment strategies and the implementation of specific documentation and care delivery processes were feasible. In two separate four-month data collection periods, chiropractors enrolled most (22/26) eligible CAF members referred for care, mostly adhered to prescribed clinical pathways, and completed and delivered most of the required documentation in a timely fashion. Reasons for lower participation of CAF members at one base and its incomplete documentation were military duty and COVID-19-pandemic-related restrictions. Although CFHS providers and chiropractors perceived enhanced communication as a study outcome, too few CAF participants completed a full treatment allotment within the study timeframe to permit a more thorough assessment of whether the processes adequately addressed previously described interprofessional collaboration barriers.⁷

Collecting data for research and clinical purposes can be facilitated by several important factors. These include adequate training of clinicians and their staff and frequent open communication and face-to-face meetings between the research and clinical members to ensure smooth implementation and operation of study-related processes.^15,34 Similarly, facilitating communication between health care providers and providing educational opportunities on study procedures were important to overcoming initial challenges with CAF participant recruitment. Additionally, enhanced emphasis on communication integrated the study protocol into clinical practice with minimal impact on clinical flow.

Although developing and implementing the PoC was feasible, the low number of CAF members referred to chiropractors and interrupted care delivery because of the COVID-19 pandemic restrictions affected evaluation. Prior research identified patient distrust in research and attempting to recruit a minority population as barriers to patient participation.^33,35 However, this was not the case in this study. Rather, the authors found that relying on a single referral source was the greatest challenge to CAF member recruitment. The recruitment of CAF members was heavily dependent on referrals from the CFHS during the data collection periods, and one of four chiropractic clinics in eastern Canada received all nine referrals. This low volume of study-eligible CAF patients limited the assessment across multiple clinic locations. The referral practices of CFHS providers to chiropractors during the study were regulated by gatekeepers, and referrals were subject to their discretion. This is consistent with prior literature describing similar non-standardized CFHS referral practices.⁷ Findings suggest that on-base meetings could address variation in referral patterns; however, this may be dependent on regional on-base leadership.

Study findings suggest that using standardized clinical reports and commonly used patient outcomes is feasible; however, completion of patient-centred outcomes requiring engagement of chiropractor and patient is more challenging and requires training. Including such standard, easily completed forms could address previously reported shortcomings in clinical reporting and communication between the CFHS and community chiropractors that were perceived as a barrier to integrating chiropractic services within the CFHS.⁷ Similar suggestions were reported in interprofessional collaborative studies between primary care physicians and chiropractors.²⁸

Findings suggest that four months may not be long enough to collect all patient data and communicate sufficiently with the CFHS because of potential disruptions to care delivery. Almost all reports for each treatment interval were delivered to the CFHS, but some were not returned according to the schedule, which could be related to interruptions in care delivery due to CAF duty obligations, chiropractors’ workloads, or administrative processes. Further research with the CAF using a multi-site approach and longer data collection periods is needed to overcome the variability in CFHS referral practices and interruptions to care delivery.

Strengths and limitations

A mixed-methods study design provided the opportunity to explore the feasibility of developing and implementing the PoC from all three user perspectives (chiropractor, CAF member, CFHS). This helped to clarify and give meaning to the quantitative feasibility outcomes. The study was also strengthened by using a multi-region approach, which allowed the researchers to overcome the initially low CAF participation rates resulting from few referrals from the CFB in eastern Canada. However, expanding participation to other diverse geographical locations may have provided different outcomes.

The study was limited by a small number of CAF member referrals, particularly in one study location, and interruptions to care delivery and follow-up data collection because of variable causes, including treatment restrictions resulting from the COVID-19 pandemic. A four-month data collection period was insufficient for collecting pre-, mid-, and post-treatment documentation for many CAF participants. Although not addressed in this study, future studies should also consider the implications of gender and other demographic factors of CAF members for referral and outcomes of care.

Conclusion

Establishing a PoC for CAF members with spinal pain designed to improve communication between chiropractors and CFHS personnel and adherence to evidence-based guidelines is feasible. A PoC with defined standards of education and documentation procedures could improve interprofessional communication between community-based chiropractors and the CFHS, encourage the transfer of evidence-based research into practice, facilitate data collection, and potentially affect outcomes. Further study is required to assess whether such a PoC affects the clinical outcomes and return to duty of CAF personnel with spinal pain.

Biographies

Silvano Mior, DC, PhD, FCCS(C), is a professor and Director, Research Partnerships, at Canadian Memorial Chiropractic College, Adjunct Professor at Ontario Tech University and the University of Toronto, and Senior Scientist at the Institute for Disability and Rehabilitation Research. His research interests include clinical outcomes and program evaluation, health services, and understanding patients’ experiences, expectations, and safety in health care delivery.

Carol Cancelliere, DC, PhD, is a scientist at the Institute for Disability and Rehabilitation Research at Ontario Tech University and Project Lead for the Canadian Chiropractic Guideline Initiative (CCGI). The objectives of the CCGI program are to develop, adopt, or adapt clinical practice guidelines relevant to musculoskeletal health and disability and engage in knowledge translation activities and research.

Corey Hofkirchner, DC, is a chiropractor and clinical instructor at the Canadian Memorial Chiropractic College (CMCC) and practices in the Greater Toronto area, Ontario, Canada. He received his bachelor’s degree from the University of Waterloo and Doctor of Chiropractic from CMCC. Hofkirchner has worked with various populations, including Canadian Armed Forces members, athletes, and those living with chronic pain. His current research interests primarily focus on the diagnosis and management of lumbar spinal stenosis and cervical and lumbar spine radiculopathy.

Gaelan Connell, MRSc, DC, is a Research Associate at the Institute for Disability and Rehabilitation Research at Ontario Tech University. He is a practicing chiropractor in a multidisciplinary clinic in Vancouver, British Columbia. He is also an editorial board member for the Journal of the Canadian Chiropractic Association. He has a keen interest in knowledge translation and implementation science.

Deborah Sutton, MSc, MEd, received her BSc (Occupational Therapy), MEd (Educational Psychology), and MSc (Epidemiology & Biostatistics) from Western University. She served as the Project Coordinator for the Canadian Forces Health Services project at the Institute for Disability and Rehabilitation Research.

Ellen Vogel, PhD, is a Registered Dietitian and conducts research exploring food insecurity and mental health among post-secondary students. She collaborates on studies exploring the opioid abuse epidemic with simulated learning for nursing students and the relationships between weight-related behaviours and sleep patterns among university students. Vogel provides qualitative expertise on a study exploring Canadian Armed Forces members’ experiences and beliefs regarding self-referred chiropractic care provided in off-base locations for the treatment of musculoskeletal conditions.

Pierre Côté, DC, PhD, is an epidemiologist and professor and Director of the Institute for Disability and Rehabilitation Research at Ontario Tech University. He is also the Ontario Tech University Research Excellence Chair in Musculoskeletal Rehabilitation.

Simon D. French, BAppSc, MPH, PhD, is a Professor of Musculoskeletal Disorders and Director of Research at the Department of Chiropractic, Macquarie University. From 2013 to 2018, he was based at Queen’s University in Kingston, Ontario, Canada, and held the Canadian Chiropractic Research Foundation Professorship in the School of Rehabilitation Therapy. He conducts research on knowledge translation in primary health care settings, with a focus on the management of low back pain and osteoarthritis.

Margareta Nordin, DrMedSci, PT, is Professor Emeritus, New York University. She was a member of the World Health Organization Package of Rehabilitation Intervention for low back pain. She has a specific interest in disseminating culturally adapted, evidence-based, low-cost, effective, and efficient rehabilitation for spine pain and spine disorders, with a focus on returning individuals to work, functional ability, and participation in the community.

Audrey Laporte, PhD, is a health economist with expertise in the application of economic theory and methods. She has conducted research in health human resource issues, such as modeling supply of providers, determinants of health professional retention, and the impact on professions, as well as health systems of scope of practice changes. Her work has included analyses of the nurse, physician, allied professional, and personal support worker labour markets individually, as well as their intersection in care settings, such as primary care.

Appendix 1.

Funding Statement

This study received funding from the Canadian Chiropractic Association, Ontario Chiropractic Association, and Canadian Chiropractic Research Foundation.