Attitudes and perceptions of health care professionals concerning chiropractors and chiropractic practice: A Systematic Review

Attitudes and perceptions of health care professionals concerning chiropractors and chiropractic practice: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Attitudes and perceptions of health care professionals concerning chiropractors and chiropractic practice: A Systematic Review Dave Newell, Amin Nouroozi, Marc Sanders, Jonathan Field, Kenneth Young, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5803290/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Chiropractic care often exists outside of national healthcare systems, with exceptions in some national settings. This situation has led to suboptimal interprofessional communication and referral, with implications for the provision of appropriate and efficient care. To find solutions, the attitudes and perceptions of other professions must be better understood. We conducted a systematic review to assess other healthcare professionals’ perceptions and attitudes towards chiropractors and chiropractic care. Methods The review was registered with PROSPERO (CRD42023403381). Reporting was guided by the PRISMA statement. A search was carried out on PubMed, CINAHL, AMED, Index of Chiropractic Literature (ICL) and MEDLINE in Jan 2021 and updated on Jan 2022, February 2023 and June 2024. We included qualitative and quantitative study designs, focusing on healthcare professionals' attitudes toward and perceptions of chiropractic. Methodological quality was assessed using the Centre for Evidence Based Medicine tools for qualitative and cross-sectional survey studies Results The search retrieved 245 articles, of which 43 were included for review. Studies had been conducted across multiple national jurisdictions A total of 10,108 participants were included across the studies, including primary and secondary healthcare professionals as well as healthcare students. Issues identified with influencing opinions of chiropractic practice included participants’ knowledge of chiropractic methods, scope of practice, interprofessional communication, research base, and education. While some participants reported a perception of positive clinical outcomes associated with chiropractic care, communication between healthcare professionals and chiropractors was often lacking. Attitudes towards chiropractic varied, with factors like knowledge, patient interest, and referrals influencing perceptions. Conclusions To improve interprofessional attitudes and perceptions, the chiropractic profession might prioritise increased communication and information access concerning contemporary chiropractic care with other health care professions including educational interventions. Mitigation of a persistent lack of reliable information may improve how the profession is perceived in general, reduce misinformation and increase the likelihood that patients will receive the joined-up care they need. Chiropractic practice Chiropractors Attitudes Perceptions Healthcare professionals Figures Figure 1 Background The chiropractic profession has found itself at self-identified crossroads several times. Such crossroads appear to highlight similar choices [ 1 , 2 , 3 ] which dichotomise into approaches to practice that embrace expectations and norms within contemporary healthcare or one that sits outside of these norms as separate and distinct. This latter option is generally associated with a historical and non-evidenced ideology in opposition to accepted guidelines and best practice [ 4 ]. Such polarised professional discourse continues to occupy significant time and effort despite such views constituting a minority of the profession [ 5 , 6 , 7 , 8 ]. In many jurisdictions across the world, chiropractic care remains outside of national health systems [ 9 ]. In the UK for example chiropractors, uniquely amongst legally registered health care professions, are not considered to be part of the national recognised healthcare work force [ 10 , 11 ]. Globally, it is typically uncommon for chiropractors to work in multidisciplinary practice or in hospitals, although there are exceptions. These are often pioneered by individual chiropractors who have forged relationships and opportunities with partnerships across the healthcare landscape [ 12 , 13 , 14 , 15 , 16 , 77 , 78 ]. In some countries, chiropractors have made inroads into national health systems; in the United States in 2019 approximately 15% of chiropractors reported working within an integrated healthcare facility with over 5% holding hospital staff privileges [ 17 ]. In other examples, such as in some Nordic countries and Switzerland, the chiropractic profession has been more successful in its acceptance as part of healthcare systems [ 18 , 19 , 69 , 77 , 78 ]. In Denmark for example, over 90% of chiropractors in private practice are partially funded by government subsidy, whilst a smaller number (approximately 5%) practice in private or public hospital settings [ 20 ]. Conversely, a UK survey in 2021 showed a decline in chiropractors working within the NHS, from 18% in 2002 [ 21 ] to just 2% [ 22 ]. The persistent exclusion of chiropractic from many national healthcare systems raises the question of why this remains the case after over a century of chiropractic care. One speculative reason may be the adherence by a minority of the profession to outdated dogma [ 23 ]. This, combined with possibly justified and/or unjustified negative perceptions from other healthcare practitioners who act as gatekeepers to healthcare systems, may hinder the profession's acceptance and integration. These attitudes can also impede contemporary patient-centred paradigms that favour interprofessional collaboration, which is increasingly encouraged and preferred by patients. The exclusion of chiropractors from these practices could limit patient access to diverse, appropriate care and negatively impact patient experiences and outcomes. Therefore, this review aims to explore the existing literature to understand the perceptions and attitudes of other healthcare professionals towards chiropractors and chiropractic practice. Method This systematic review has been written up in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.[ 81 ] Literature Search An initial scoping search was conducted in 2021 to refine the research question and construct the full review protocol which was published on PROSPERO (CRD42023403381). A detailed search strategy was developed and derivatives and synonyms of key terms describing non chiropractic professionals, attitudes and perceptions was used. An example of search string is shown in Table 1 . Databases searched included PubMed, CINAHL, AMED, Index of Chiropractic Literature (ICL), and MEDLINE. Initial searches were conducted in January 2021, updated in January 2022, February 2023, and June 2024. There were no date restrictions. Table 1 Example Search Terms #1 [MH "Physicians, Family"] OR [MH "Physical Therapists"] OR [MH "Occupational Therapists"] OR [MH "Nursing Assistants"] OR [MH "Physical Therapist Assistants"] OR [MH "Nurses+"] OR “general practitioner*" OR “nurse’ OR “occupational therapist” OR “Physiotherapist” OR “Physical Therapist” OR “surgeon” OR [MH "Surgeons"] #2 [MH "Chiropractors"] OR [MH "Chiropractic Practice"] OR [MH "Chiropractic"] OR [MH "Manipulation, Chiropractic"] OR “Chiropract*" #3 #1 AND #2 #4 [MH "Attitude of Health Personnel+"] OR “attitude” OR “perception” #5 #3 AND #4 Article Selection Articles that met the following criteria were eligible for inclusion in the review: 1. focused on specific exploration of attitudes/perceptions/beliefs of any health professionals (including students) concerning chiropractic/chiropractors or chiropractors using spinal manipulative therapy, 2. primary empirical studies: qualitative, quantitative, and mixed methods, 3. published in English. Papers were excluded if they were: 1. general CAM surveys which did not specifically mention attitudes/beliefs or views concerning chiropractic, 3. if they only explored referral rates without exploring attitudes/beliefs or views of other health care professionals, 3. case studies, non-empirical studies, secondary research, and studies where only the abstract could be sourced were excluded. Titles and abstracts were screened independently by two authors (KY and JF) using pre-determined inclusion and exclusion criteria. Any variation was agreed upon between these authors and disagreements were resolved, if necessary, with the assistance of a third author (DN). Full texts were read by two reviewers (AN and DN) and data extracted independently. The screening and selection of studies is documented in the PRISMA in Fig. 1 . Data extraction and Analysis Data extraction included Title, Author, Date, Design/Method, Jurisdiction, Population, Analysis and Results. Quality assessment was conducted by two reviewers (AN and DN) using the Centre for Evidence Based Medicine (CEBM) qualitative and cross-sectional survey quality assessment tools [ 26 , 27 ]. For the quality assessment we categorised the total scores into approximate thirds to provide 3 quality categories (Low, Medium, High). Data extraction and synthesis was also conducted by these two reviewers using a narrative synthesis to collate and integrate the findings of the included studies. [ 24 , 25 ]. Results Study Characteristics and overview Forty-three studies were identified as eligible to be included in the review. (see Fig. 1 ). Included studies are categorised by country in and Table 2 . Due to delays caused by the COVID-19 pandemic and subsequent delays in registration of the protocol we performed follow up searches in 2022 and 2023 finding one additional eligible study [ 28 ]. A final search conducted in 2024 failed to identify any further eligible studies. Table 2 Characteristics and results of included studies. Citation Design/Method Population Results AUSTRALIA Preston-Thomas et al., (1993) • Design: Survey • Format: Written questionnaire ,12 multiple choice questions, questionnaire was mailed • Sampling: 100 GPs in the Auckland area • Validity: Piloted on a small sample of 5 GPs GPs Response rate: 49 GPs responded (49%) Results: • 97% felt that referral by them should always be necessary before spinal manipulation therapy. • 40% had moderate to excellent knowledge of chiropractic. • Knowledge source: 65% from patients, 45% personal communication with therapist, 15% from the media • 9% of GPs have experienced manipulative therapy themselves. • GPs who rated themselves as having the greatest knowledge of chiropractic were significantly more likely to refer patients with chronic pain to chiropractic (p < 0.001) than GPs with less knowledge of chiropractic Hopper and Cohen (1998 • Design: Survey • Format: Questionnaire • Sampling: 1097 1st, 3rd, and 5th year medical students • Validity: Not documented Medical Students Response rate: 800 students responded (73%) Results • Generally positive towards complementary therapies • Students reported little knowledge of chiropractic despite it being at the time, one of two most common complementary therapies in Australia Simpson (1998) • Design: Survey • Format: Questionnaire • Sampling: Pseudo random (every second on official list of 3018 I.e., sample 1509) • Validity: Not documented GPs Response rate: 784 GPs responded (52%) Results • 82% Male • Percentage replying affirmative to following questions comparing Physiotherapists and Chiropractors ▪ Legitimate care providers: Chiro 23%/ Physio 95% ▪ Treat in hospitals: Chiro 14%/ Physio 95% ▪ Remain primary care: Chiro 29%/Physio 63% ▪ Ethical to deal with: Chiro 35%/ Physio 99% Pirotta et al., (2000) • Design: Survey • Format: Questionnaire • Sampling: Survey was mailed to 800 (764 after removal of 36) GPs: non-responders were sent a reminder postcard and follow-up survey if necessary • Validity: Survey was developed from existing literature and using a focus group of GPs GPs Response rate: 488 GPs responded (64%) Results • 82% Male • 80% reported they knew something about chiropractic. • 7% thought chiropractic care was frequently harmful, 75% occasionally harmful, 17% not often harmful. • 11% thought chiropractic is Highly effective, 70% occasionally effective, 14% not often effective. • 55% of GPs would practice chiropractic with appropriate training, and amongst these, 69% said that chiropractic should be eligible for Medicare rebates (national health insurance scheme) • 29% of respondents have had patients ask them for a referral, 69% have never referred, 78% have rarely or referred a few times a year and 22% either monthly or weekly refer patients to chiropractors. • 24% of GPs are interested in training for chiropractic and 8% already had trained. Wardle et al., (2013) • Design: Survey • Format: Questionnaire • Sampling: Survey was mailed 1486 GPs and a reminder card was sent after two months. • Validity: Survey based on a previous questionnaire and was piloted at the department of general practice in the University of Newcastle. GPs Response rate: 698 GPs responded (40.7%) Results Descriptive analysis : • Modal age 45 to 55, 53.5% were male. • 23.1% of GPs referred to a chiropractor or osteopath at least once per month, 41.0% at least few times per year, 21.7% stated they would not refer to a chiropractor or osteopath. • Only 2.2% were unable to identify practitioners to refer to • 10.4% of respondents performed manipulative therapies themselves (chiropractic or osteopathic techniques), 21.2% had a personal professional relationship with a specific individual chiro or osteopath. • Significantly more likely to refer if they had a high patient load or had knowledge of chiropractic or osteopathy. Inferential analysis : • GPs who believed in the efficacy of chiropractic or osteopathy, had seen positive results or who perceived access to medical specialists not being a driver for CAM use were significantly more likely to refer. • GPs who had not seen positive result were 2.41(95% CI: 1.18, 5.12) time more likely to refer if there was no other option available. Engel et al., (2016) • Design: Survey • Format: Questionnaire • Sampling: Survey was mailed 24,377 GPs currently working in Australian private practice • Validity: Tested on a focus group of 19 experienced vocational trainers at GP conference GPs Response rate: 630 GPs responded (2.6%) Results • Greatest proportion of respondents were > 40 and had < 10 years in practice compared to the national average. • 30% obtained information about chiropractors from medical journals. • 66% disagreed that there was a growing body of evidence on the efficacy of chiropractic 70% believed chiropractic education was not primarily evidence based. • 62% responded in a negative way to "would a better understanding of chiropractic make you reconsider referring a patient to a chiropractor?" 32% agreed they would co-manage a patient with a chiropractor if clinically appropriate. • 29% strongly agreed or agreed that the ability to understand the role of a chiropractor have been affected by media coverage. • 31% were either dissatisfied or very dissatisfied with the communication between themselves and chiropractors, 41% hadn’t had enough communication to respond to the question. • 49% reported having patient referred to them by a chiropractor. • 68% reported not being interested in learning more about the education of chiropractors. • Top three conditions that GPs thought chiropractors could be helpful were: mechanical LBP, neck, and upper BP, cervicogenic headaches. Grace et al., (2018) • Design: Qualitative: Critical Realist analysis of free text responses of prior survey (Engel) • Format: NA • Sampling: Original survey targeted the 24,377 GPs currently working in Australian private practice • Validity: NA GPs Response rate: 184 GPs responded with free text (0.7%) (original survey, Engel) Results Themes 1. Chiropractic Is Not a Safe Practice 2. There Is a Lack of Evidence to Support Chiropractic and Osteopathy 3. Chiropractors and Osteopaths are insufficiently trained and should not be allowed to practise as primary contact health practitioners. 4. Chiropractors make financially motivated decisions about treatment that are associated with false advertising. 5. Chiropractic and osteopathy are redundant due to the presence of physiotherapy. . • Unfavourable responses towards chiropractic were far greater than osteopathy. • 13% raised concerns about the potentially harmful side effects associated with chiropractic but not osteopathy. • 21.7% referred to the lack of evidence for the efficacy of chiropractic intervention. A similar proportion also raised the same concerns regarding osteopathy. • 12% reported chiropractic and osteopathy offered real benefits particularly for MSK issues but cited the mechanism as due to patient belief. • 24.5% raised issues of credibility with the education background of chiropractors. • 10.3% referred to unwillingness to refer patients to chiropractors due to an inability to identify "good" and "bad" chiropractors. • 73% identified the antivaccination stance of some chiropractors as problematic. • 32.1% concerned about chiropractors making financially motivated decisions and their use of false claims about the benefits of chiropractic intervention in advertising. • GPs expressed the opinion that they can refer patients to physiotherapists for treatment of MSK conditions making chiropractic and osteopathy redundant. CANADA Newton-Leo et al., (1994) • Design: Survey • Format: Questionnaire • Sampling: All (148) GPs listed in Canadian Medical Association in Downsview were contacted. Of these 70 were sent the survey based on expectation they would response based on secretary’s advice. • Validity: Revision of a questionnaire used by LeBrun et al (1978) including rewording some questions and deleting others. Survey underwent face validity with professionals and lay public. GPs Response rate: 26 GPs responded (37%) Results • 69% unaware of length of training Some thought reflexology, homeopathy and iridology were part of the curriculum (54,31 and 19% respectively) • 92% thought chiropractors diagnosed MSK, but only 65% felt they could control pain • Only 31% were aware that risk of cardiovascular event due to cervical spine adjustment was very low. • 88% had refereed and 65% had had referral 23% had been treated Opinions: 91% positive to neutral; agreed working with chiropractors collaboratively would improve patient’s health Verhoef and Sutherland (1995) • Design: Survey • Format: Questionnaire • Sampling: Mailed to 400 GPs (200 Ontario, 200 Alberta). Subsample of non-respondents were mailed a brief one-page questionnaire addressing age, sex and perceived usefulness of complementary medicine. • Validity: Survey was adapted from a previous questionnaire and rated the practitioner’s level of knowledge of chiropractic, usefulness, and effectiveness GPs Response rate: Alberta 124 (62%), Ontario 86 (43%), non-respondent survey (43%) Results • Majority male 69%, urban practice (69%), mean age 44 SD = 9.5 • 65% said there is a perceived demand for complementary therapy. • 44% of the total sample stated they referred patients to chiropractors. • Ontario physicians were more likely to refer patients (60% and 32% respectively) • Referrals were predominantly back pain, MSK pain, chronic pain. Reason for referral were non-response to conventional medicine and patient preference. • Only 1 participant had received training on chiropractic and 6% wished to receive training1/5th of the participants indicated that chiropractic influenced their opinion on complementary therapy. • Level of "some" knowledge (majority of respondents): Ontario (65%) Alberta (68%) • General usefulness: Majority "Useful," Ontario: 43% Alberta: 52% • Effectiveness for neck/back pain problems: Majority "Somewhat" Ontario: 35%, Alberta: 44% Verhoef and Page (1996) Comments extracted via secondary analysis of above survey (Verhoef et al, 1995) GPs Results • Approximately 1/5th of the comments offered by participants mentioned chiropractic specifically. • Positive Views : Most of these comments suggested that the positive view of chiropractic was due to feedback/results heard/observed in patients or family members who had received chiropractic care or because of chiropractic services they had received or from professional interactions they had with them. Only two practitioners reported positive views arising from reading scientific literature. • Balanced views : Around a ¼ of respondents provided both positive and negative experiences regarding chiropractic. Management of MSK conditions was deemed appropriate but was not considered so for non MSK (e.g., asthma, diabetes. These views arose from anecdotal reports from patients. • Negative views : Only 5 respondents provided negative responses with some suggesting that chiropractors focused on financial gain. Garner et al., (2008) • Design: A mixed method • Format: Questionnaires and Focus Groups • Sampling: Two community health centres (CHCs) in Ottawa, Ontario. Assessment was recorded at baseline 9 months and 18 months after chiropractor joined. Educational sessions were run to post first 2 focus groups to expose providers to evidence-based chiropractic. • Validity: Questionnaire used a seven-point Likert scale and was pilot tested including face validity at both CHCs before the study began Physicians Nurses Population: Twelve providers were assessed Results • Mean age was 44.1 years of age, range of experience 2-5years, each practitioner had worked for 5 + years. • There was a statistically significant (P = 0.004) increase willingness to trust chiropractic in shared care cases and greater respect for the chiropractor’s knowledge and skills (p = 0.008) post educational intervention. • Further changes were also noted post inclusion of the chiropractor including, legitimacy and effectiveness of chiropractic moved from neutral to more positive, providers indicated that chiropractic care was safer than anti-inflammatory medication, scepticism about efficacy and safety was "dissipated" and questions regarding experience with chiropractic and patient outcomes moved from neutral to positive Analysis of focus group data saw a shift within medical teams from a negative and limited view of chiropractic to generally more positive attitude. E.g., thick quotes included, "I have only had positive feedback from many of the clients; they have always had some sort of change in their outcome, and they have always had some sort of positive thing to say." " We are able to give patients hope and encouragement, and actually, I have a lot of patients that it (chiropractic) helped with their pain reduction and certainly has taken the burden off me psychologically and time wise" Busse et al., (2009) • Design: Survey • Format: Questionnaire • Sampling: Random sample n = 500 for both Canada and US. Power calculation for multivariable regression suggested 240 completed returns were needed. Canadian (total population 764) and US (total population 24,172 • Validity: Chiropractic Attitudes Questionnaire CAQ Orthopaedic Surgeons Response rate: 680 completed surveys from 1000 sent (68%) Results • 71% not exposed to information on chiros during medical school (of the 139 that were only 7% reported favourable exposure) • 86% respondents said attitudes were formed after medical school (29% positive views/45% negative views) • US more likely to agree that neck manipulation is safe and there are ideas that could benefit wider healthcare/ Canadian more likely to agree chiro had adequate training, did not engage in aggressive marketing, and did not breed dependency. • Variables that were associated with attitudes were, relationship with specific chiropractor, Research literature, medical school, and age Busse et al., (2011) • Design: Thematic analysis of written comments in above survey (Busse et al, 2009) Orthopaedic Surgeons Response rate: 680 completed surveys from 1000 sent (68%) and 174 provided written comments (25% of original 680 respondents) Results: Themes identified • Variability amongst chiropractors “Wide range of practice - some are evidence based...others do all sorts of crazy stuff“ • Chiropractic care perceived as effective “I find their usefulness is limited to lumbar mechanical back pain care“. • Chiropractic care perceived as unhelpful/problematic “Chiropractors are dangerous when they portray themselves as replacements for patients’ primary care physicians“ • Chiropractic rationale “The concept of ‘adjusting subluxations’ is nonsensical”. • Chiropractic training “Life chiropractors are scary“, and “I visited the Canadian Memorial Chiropractic College in Toronto. I was impressed with the similarity of their basic science curriculum - same books as used in medicine - and the extent of information covering all symptoms. This does not seem to be the case for all schools in North America“. • Unethical behaviour “Major problem as I see it, chiropractors tend to place patients on an ‘x amount of treatment’ plan such as 20 visits. In my opinion they need to perform the service and see if the patient responds and proceed from there. Not just say ‘you need an x amount of treatment’ plan“ • Scientific basis “Most students now have undergraduate degrees and are relatively well educated in basic sciences in their first 2 years (preclinical). The problem begins when they move into their clinical years where education becomes ‘indoctrination’. “ • Personal experience “I need more knowledge to utilize chiropractors better!“ Chung et al., (2012) • Design: Questionnaire intervention: Implicit association test (IAT) developed to test attitudes toward chiropractic and medical care • Sampling : A convenience sample was recruited from students and faculty associated with a Physical Therapy program. • A survey determined which words best reflected the profession of either chiropractic or medicine. These words were used in the word association task of the IAT. • Explicit questions followed by a list of words were developed. Physical therapy students and faculty Participants: Total of 49 participants, majority female and mean age of 29, majority in 1/2nd year, only 29% previous experience Results • Most had a preference of medical treatment (91% preferred and 81% agreed with medicine) • Explicit prejudice was an average of 53% which might be considered neutral rather than prejudiced or accepting. • Implicit attitudes suggest strong negative implicit bias toward chiropractic (That is, the word association task took statistically significantly longer to complete when “chiropractic” was paired together with “positive” terms than when “chiropractic” was paired together with “negative” terms) Wong et al., (2013) • Design: Mixed methods approach (survey, interviews and focus group) • Format: Questionnaire, 20 min interviews and single focus group (1hr). • Sampling: Survey, all of Year 2 n = 224); Focus Group n = 8; Interviews n = 9 • Validity: developed through a literature review to discern thematic areas suggested by current studies. Face validity using 4 students. Medical Students Response rate: 112 completed surveys (50%), equal female/male ratio Results Quantitive • Responses to questions positive, negative, undecided • Largest proportion had poor knowledge of chiropractic. • Individuals with poor knowledge significantly indicated don’t know/undecided to questions. • Individuals with previous experience indicated more positive (if friend or family member then considered it as a career, received chiropractic care and more positive) • Individuals who responded no to learning more about chiropractic were significantly more negative attitudinally. • Highest proportion undecided as to chiropractic being a mainstream profession but agreed it was CAM. • Highest proportions were undecided that the medical school was knowledgeable about chiropractic but agreed that Interprofessional education was important. Qualitative Themes • Knowledge of chiropractic “I do remember hearing some injuries that can be caused when people have some specific condition, but I don’t think we’ve ever had anything really too positively that I can recall in lecture.” • Chiropractic in medical education “We did have an interprofessional development day… and there weren’t any alternative medicine or chiropractors, and I feel that would be a good opportunity to introduce students to it.” • Role of chiropractic in healthcare “If I were the practicing physician, I may not choose (chiropractic) treatment for a patient just because I don’t understand it. If I understood the risks and benefits to particular patients, I would definitely have a positive attitude towards it and know when to access it.” • Chiropractic in clinical settings “If (chiropractors) are part of the same healthcare team then it would be easier for the patient to access all the services in the same place and part of the same group of circle of care.” Wong et al., (2014) • Design: Mixed methods (survey and focus group) • Format: Follow up using survey used in study above (Wong et al 2013) post a 1 hr intervention • Sample: As above • Validity: As above Medical Students Response rate :Of 112 students (50% of class) 58 responded (26% of class) post 1hr intervention. Results • Attitudes differed between pre and post intervention. • A statistically significant increase in number of attitude-positive responses (p < .0001), decrease in attitude-negative (p .03) and decrease in undecided responses (p < .001). • In terms of understanding of chiropractic, post intervention, participants ranked themselves significantly higher as a group (p < .0002) and a larger percentage rated themselves as having at least a ‘‘Good’’ understanding of chiropractic (35.1% vs 21.5%) Weis et al., (2016) • Design: Survey • Format: Online questionnaire • Sample: 659 or 1433 members of the Society of Obstetricians and Gynaecologists of Canada • Validity: Modified existing survey was designed to assess attitudes of obstetricians towards chiropractic care for pregnant patients with LBP. Added Chiropractic Attitude Questionnaire (CAQ). Piloted with a group of 5 staff obstetricians. Obstetricians Gynaecologists Response rate : 91 completed surveys ((14%) Results • 63.7% Female, 78.1% practiced for > 5 years, 54.9% practiced in hospitals, 84% endorsed general obstetrics as their area of specialism. • Positive, neutral, or negative views equally distributed in the sample. • 40% referred at least some patients for chiropractic care each year; patient request (31.9%) nonresponse to medical treatment (20.9%). • Views of chiropractic primarily from patient feedback (48.4%), family and friends (39.6%), personal treatment experience (26.4%), or a relationship with a specific chiropractor (20.9%). • Most respondents (56%) were interested in learning more about chiropractic care. • Mean CAQ score was 41.2 (max positive score obtainable was 80) • Most participants strongly agreed or agreed that chiropractors provide effective therapy for some musculoskeletal conditions (76.6%), that chiropractors provide a patient- centred approach (57.7%), and that chiropractic care is a useful supplement to conventional medicine (60.0%). • Most respondents disagreed (32.2%) or strongly disagreed (42.2%) that chiropractors can provide effective therapy for non- musculoskeletal conditions, and 54.4% of respondents disagreed or strongly disagreed that chiropractic manipulation of the neck is a safe therapy. • 39% viewed chiropractic care as effective for pregnant patients with LBP. • Trend suggested personal experience with chiropractic resulted in higher scores. • No variables significantly predicted positive attitudes although personal treatment experience was near statistical significanc Busse (2021) • Design: Survey • Format: Questionnaire • Sampling: Follow up survey (Busse et al 2009) of a random sample of Canadian family physicians (directory of possible 2429 participants). • Validity: Chiropractic Attitudes Questionnaire CAQ Family Physicians Response rate: 162 respondents (7%) Approximately half of respondents Results • Majority endorsed a positive impression of chiropractic care, but a quarter held negative views. • Most respondents referred at least some patients for chiropractic care. • Most physicians believed that chiropractors provide effective therapy for some musculoskeletal complaints and most disagreed that chiropractic care was beneficial for non-musculoskeletal conditions. • The majority agreed that chiropractic care was a useful supplement to conventional care, but most respondents also indicated that practice diversity among chiropractors presented a barrier to interprofessional collaboration. • Attitudes towards chiropractic care changed trivially over the decade from the original survey in 2010 to present survey in 2019 with only 1/3rd of a point improvement on an 80-point scale. • More negative attitudes were associated with older age, belief that adverse events are common with chiropractic care, reported use of the research literature or medical school as sources of knowledge. • More positive attitudes were associated with endorsing a relationship with a specific chiropractor. Zivcic (2014) • Design: Survey • Format: Questionnaire • Sampling:. Snowball method (chain of referrals that starts with the identification and locating of a certain number of target population members that satisfy the pre-established criteria) • Validity: MAQ (Integrative Medicine Attitude Questionnaire). Modifications made in translation to Croatian. Larger the score more favourable Physiotherapists Physicians Nurses Paramedics Response rate: n = 325 replied, 104 Physiotherapists, 98 Physicians, 123 Nurse/Paramedics. (response rate not reported) Results • Single question referring to chiropractic care: Chiropractic is a valuable method of resolving a wide variety of musculoskeletal problems (not just back pain); Maximum score is 7 where 1 is absolutely disagree and 7 is absolutely agree. • Physicians mean score, 3.41. • Physiotherapists mean score, 3.33. • Nurses/paramedics mean score 3.59. • No statistical difference between groups. NETHERLANDS Langworthy et al., (2000) • Design: Survey • Format: Questionnaire • Sampling: Random sample of 299 Physiotherapists (Ps) from a list of 500 provided by national association. Also sent to 100 Manual Therapists (MTs) and 95 Osteopaths (Os) (Total 494) • Validity: Survey constructed for the study around opinions about chiropractic. Piloted for face validity. Physiotherapists (Ps) Osteopaths (Os) Manual Therapists (MTs) Reponses rate: 237 responses returned (48%)) (Proportions, 50% MTs, 45% Ps, 52% Os) Results • Most Os and MTs were male whilst most Ps were female. • 70% Os thought it their knowledge was good but only 1% of MTs and 7% of Ps said they had only heard something. • 1/3rd encountered chiropractic care through their patients. • 10% of Ps and 25–33% of MTs and Os had heard of chiropractic during training. • Around 1/5th of Os and Ps heard through media although this was least preferred with most preferring information via published research. • Around 1/2 MTs and 2/3rd Ps and Os had had no contact with chiropractors • Existing levels of communication and cooperation between the professions was considered poor to non-existent by over 80% of respondents; felt it should be improved and would help professionals and patients. • All Os and 1/2 MTs and Ps thought chiropractors were skilled practitioners especially if they had personal experience but around 2/3 of MTs and Ps saw chiropractors as competition. • MTs and Ps were generally unsupportive of statutory registration of chiropractors in The Netherlands. Brusse et al., (2001) • Design: Survey • Format: Postal questionnaire • Sampling: 252 questionnaires were sent to GPs in 84 cities where chiropractors were working with addresses obtained from The Netherlands Institute for Research in Primary Care, which randomly chose 3 addresses in each city • Validity: Piloted by stakeholder GPs Response rate: 115 returned questionnaire (46%) Results • Knowledge about chiropractic was high although the depth of knowledge varied extensively. • 78% of knowledge came from patients being treated by chiropractors the rest from colleagues or medical journals (26%, 25%) • 10% of GPs regularly referred. For those that did it was significantly related to knowledge of or positive relations with chiropractors • > 80% wanted more information about and more feedback from chiropractors even if they didn’t refer. • GPs felt Chiropractic reports often contained confusing terminology NEW ZEALAND Poynton et al., (2006) • Design: Survey • Format: Postal questionnaire • Sampling: Nationwide random sample of 500 GPs from a population of 2358 were mailed a two-page questionnaire. A second questionnaire was sent to non-responders 2.5 weeks later. • Validity: Informed by previous research GPs Response rate: 300 of the 499 eligible practitioners replied (60%) Results • Mean age was 50.3. • 42.7% saw chiropractic manipulation as conventional medicine. • 79.7% of respondents rated chiropractic as moderately, very, or highly beneficial. • 77.7% have referred to a chiropractor. NORWAY/SWEDEN Westin et al., (2013) • Design: Survey • Format: Postal questionnaire • Sampling: Sent to every other GP in proportionate numbers to the numbers of GPs in Sweden and Norway. N = 1600 surveys sent • Validity: Informed by 2 Master-projects from the Anglo-European College of Chiropractic in England. GPs Response Rate: 735 total returned (Sweden, 44.8%; Norway, 45.3) Results • Around half of GPs were older than 50 with around 60% being male in both countries • In Sweden over 50% said they had poor knowledge and in Norway 12% • Regarding education as being satisfactory, 49% and 80% agreed in Sweden and Norway respectively. • Regarding competency to treat MSK, 69% and 93% agreed in Sweden and Norway respectively. • Unusual terminology was perceived by 11 and 23% in Sweden and Norway respectively. • Regarding patient experience, 47% and 66% agreed this was good in Sweden and Norway respectively. • Only 12% and 3% agreed a variable or bad patient experience in Sweden and Norway respectively. • GPs stated they had been asked about recommendation (43% and 79% Sweden and Norway respectively) (NB: GPs in Sweden cannot refer) SOUTH AFRICA Louw and Myburgh (2007) • Design: Survey • Format: Postal questionnaire • Sampling: Random sample of 596 practitioners were drawn from medical practitioners in South Africa, working as GPs in one of five selected cities. Total population of 4448 GPs in private practice (South African Medical Association database), • Validity: Questionnaire developed by Langworthy et al, 2000) GPs Response rate: Participants returned 596 questionnaires (13.8%) Results • 80% knew something about chiropractic, 20% nothing 43% communicated, 9% regularly: just over half respondents reported positive experience. • There was a highly statistical associated with how much knowledge GPs reported and referral/communication. • GPs strongly identify chiropractors with the management of neuro-musculoskeletal disorders. • 44% were in favour of regular chiropractic visits to prevent the onset of recurrent conditions. • Role of the chiropractor is perceived as one of referral and rehabilitation, rather than primary contact. Example quotes • Chiropractic provides a useful, non-invasive modality for numerous medical conditions, especially back and other musculoskeletal pain.; Chiropractors are very under-utilized; they could do much more, doctors need to know more about what they do. • I don’t feel chiropractors add greatly to the health of general population especially the poor.; I am not sufficiently informed about chiropractors and their ability, to refer patients to them. I feel that physiotherapists are best able to deal with these problems and I get good results with them.: Chiropractors tend to overtreat. Naidoo and Bühler (2009) • Design: Survey • Format: Questionnaire • Sampling: Questionnaires given to first and final-year physiotherapy (n = 72) and chiropractic students (n = 49) (n = 127 in Durban, KwaZulu-Natal.) • Validity: The questionnaire was piloted for content validity using second year physiotherapy students. No changes were made post the pilot study. Physiotherapy Response rate: 38 1st year and 34 final year physiotherapy students responded (100% return rate) Results • 92%, 85% female and mean age was 19 and 22 in year 1 and 4 respectively. Percentage knowledge of chiropractic average score for 1st and final year students was 58 and 62% respectively. • Proportion of class who saw the chiropractors as direct competition was 84% and 76% in 1st year and 4th year respectively (The main reason cited for this is that “Physiotherapists and chiropractors do things that are similar” or “Chiropractors do everything originally done by physiotherapists” • Four percent of the first-year students felt “rehabilitation is not done by chiropractors.” Final year physiotherapy students felt that the skills physiotherapists have are “more and different” with “treatment of the chest and musculoskeletal system.“ • Six percent felt that “Chiropractors are doctors but do things that are actually physiotherapy techniques.” • Forty five percent first year and 53% final year physiotherapy students reported that they would like to work more closely with chiropractors. Physiotherapy students listed some of the following as barriers or facilitators for improved working relations with chiropractors as follows: • “Chiropractors take over the Physiotherapists job”. • “Unfair that Chiropractors are called doctors; what about physio- therapists? • ”Both professions are equally important, but their domains should be separated”, “Would like to know more about chiropractors”. • “Physiotherapy needs to be marketed more”. • “There is place for both professions, therefore there is no need for competition”. • “Both professions need more knowledge and information about each other.” Thondhlana et al., (2021) • Design: Survey • Format: Postal questionnaire • Sampling: Total population of 88 registered private GPs in Harare as of October 2017. Sample size calculation (95% confidence interval) suggested 72 doctors as appropriate to provide generalisability to the entire population of GPs in Harare • Validity: A self-administered questionnaire, adapted from those used in similar studies GPs Response rate: 48 respondents (55%) Results • Approximately one-third had never heard of chiropractic care. • Of the two thirds that had, almost 66% believed chiropractors to be competent in the treatment of musculoskeletal complaints and approximately one-third in the treatment of neurological ailments. • 40% of GPs believed that chiropractors were adequately trained to play a role in mainstream medicine, but the majority were unsure whether chiropractors’ education was adequate in this regard. • More than half of the respondents agreed with chiropractic referral for musculoskeletal conditions. • GPs perceptions rather than knowledge appeared to determine the utilisation (referral) of chiropractors by GPs. Main reason for non-referral of musculoskeletal complaints to a chiropractor was lack of knowledge by the GP followed by uncertainty of treatment efficacy and the belief that there were no chiropractors in the area • GPs who were more knowledgeable also had more positive perception of the profession. UK Perkin et al., (1994) • Design: Survey • Format: Questionnaire • Sampling: Questionnaires sent to 100 randomly selected GPs and hospital consultants and 237 preclinical medical students from two UK schools. A second questionnaire was sent to non-responders. • Validity: Not reported GPs (GPs) Hospital Doctors (HDs( Medical students (MS) Response rate: 87 GPs, 81 HDs and 230 MS completed questionnaires (87% GPs, 81% HD and 97% MS) Results • 51% of MS, 91% of HDs and 82% of GPs had heard of chiropractic. • 15% of MS, 49% of HD, and 60% of GPs knew the principles of chiropractic. • 5% of MS, 8% of HD, and 33% of GPS knew the qualifications needed to be a chiropractor. • In all three of these items GPs were statistically significantly more knowledgeable • In terms of referral to chiropractic 14% of HDs referrals were suggested by the doctor and 7% was suggested by the patient. In contrast, 54% of GPs referrals were suggested by the doctor and 51% were suggested by the patient a statistically significant difference between professionals. • In comparison to the other alternative therapies, significantly less medical students had heard of chiropractic. White et al., (1997) • Design: Survey • Format: Questionnaire • Sampling: All GPs on register in Devon and Cornwall (n = 972). • Validity: Piloted questionnaire created by authors GPs Response rate: 461 returned questionnaire (47%) Results • 77% Male • 46%% either referred to or endorsed chiropractic (highest of the CAM therapies mentioned in this study), with the most common profession referred to in the previous week being osteopathy or chiropractic (18% referred 63% recommended) • 69% rated osteopathy and chiropractic as effective (highest rating) and 56% thought chiropractic care should be included in the NHS (slightly higher than Osteopathy (52%)) • Adverse events were mentioned by 38% most being around spinal manipulation Perry and Dowrick (2000) • Design: Survey • Format: Postal questionnaire • Sampling: Questionnaires sent to all GP principals registered with Liverpool Health Authority (n = 252). One reminder was sent to non-responders 3 weeks later. • Validity: Piloted with 20 GPs, five clinical members were also used to ensure reasonable response rate GPs Response rate: 131 questionnaires were returned (52%) Results • Younger doctors were significantly more likely to respond than their older colleagues. • 7% or GPs refereed and 11% endorsed chiropractic care. • 1 GP used manipulation with their patients. Schmidt et al., (2002) • Design: Survey • Format: Postal questionnaire • Sampling: In the UK, the local health authority provided a list of addresses for GPs by electoral ward in the Plymouth area. This list did not constitute a random sample but was ordered according to geographical area (n = 97). German GPs were selected by randomly choosing addresses from the Yellow Pages for Mecklenburg Vorpommern, a north-eastern region in Germany (formerly German Democratic Republic) (n = 99) • Validity: Questionnaires developed based on previous literature and piloted GPs. GPs Response rate UK 133 (69%), Germany 67 (68%) Results • Majority were male (94% UK and 63% German). British sample practicing longer. • Overall, more positive in Germany than UK toward CAM in general • The most popular UK GPs referred their patients to were chiropractic treatment (79%), acupuncture (67%) and osteopathy (66%). • German GPs referred their patients mainly to acupuncture treatment (82%), chiropractic treatment (73%) and herbal medicine (28%) • Most GPs, irrespective of country, were concerned about the lack of scientific evidence about CAM. British GPs were also highly concerned about lack of knowledge about its indications and the lack of availability on the NHS. • 8% and 11% of UK and German GPs claim to have practiced chiropractic and 6% of UK GPs had used chiro (the highest use) and 7% in Germany (second highest) Davidson., (2007) • Design: Survey • Format: Postal questionnaire • Sampling: Postal survey GPs in Grampian, Scotland with 433 receiving the questionnaire • Validity: Questionnaire designed for study GPs Response rate: 135 completed the questionnaire (31%) Results • 48% had heard of chiropractic treatment for children and 11.8% knew of a chiropractor in the area who treated children. • 74% would prefer written communication and 78% would communicate by letter to a chiropractor. • 60% would like to know more about the efficacy and scope of practice. • < 1% GPs believed chiropractic paediatric care is evidence based. • 46% of GPs believed chiropractic can treat sports injuries, scoliosis 37%, torticollis 37.9%, growing pains 31.1%, headaches 25.2%, colic 20% • 4.4% had received paediatric referral from chiropractor and 2.2% had referred a child to the chiropractor Kier et al., (2013) • Design: Survey • Format: Postal questionnaire • Sampling: 385 GPs were contacted representing approximately 20% of the GPs in Wales. • Validity: Short questionnaire was designed and initially piloted internally for face/construct validity GPs Response rate: 182 participants completed the questionnaire (51%) Results • 64.8% were male and 79% were 40+ • 26.4% of GPs had personally sought treatment from and 72% indicated that they had referred a patient to a SMT practitioner. • 21% GPs indicated they have not and would not refer a patient to a SMT practitioner. • 13% of GPs personally would seek of consider seeking chiropractic therapy specifically and 7% would consider referring their patient to chiropractor. Perry et al., (2014) • Design: Survey • Format: Postal questionnaire • Sampling: Sent to all GPs registered with Liverpool Primary Care Trust. Reminders were sent at 3 weeks and further postal drop at 3 months. • Validity: Questionnaire was adapted from the one used Perry (2000) GPs Response rate: 78 returned the survey (32%) Results • Changes since 2000 survey was a reduction in referral (7–4%) and endorsement (11–8%) but an increased confidence in discussing chiropractic (18 to 28%) • Only 8% of those that completed the questionnaire discussed chiropractic with patients. • Mean effectiveness of chiropractic was judged as second highest of included CAMs (44%, where 100% represented completely effective) • 40% of respondents reported that their patients had experienced benefit from chiropractic care in the past three months. • Most frequent adverse event observed was increased pain from chiropractic manipulation. USA Reiter (1965) • Format: Face to face interview • Sampling: 33 randomly selected physicians were interviewed. • Validity: Questionnaire was adapted from the one used Perry, 2000 (REF). Physicians were asked to use a 5-point Likert scale to answer the questions (1 = extremely unfavourable; 5 extremely favourable) Physicians Response rate 33 participants completed the interviews (100%) Results • Mean ranking across three professions: Podiatrist 3.2, Osteopaths 2.7, Chiropractors 1.3 • Ratings indicated that chiropractors are generally very unfavourably perceived compared to osteopaths and podiatrists. • Total average rating for osteopaths and podiatrists were significantly higher than that for chiropractors Gordon et al., (1998) • Design: Survey • Format: Postal questionnaire • Sampling: Questionnaires were sent out to 1027 Physicians and 225 Obstetricians and Gynaecologists. • Validity: Not reported Physicians Obstetrics Gynaecologists Nurses Response rate: Physicians n = 624 (61%) Obstetrics, Gynaecologists n = 157 (70.4%) Results • 34% of adult primary care clinicians and 38% of Obstetrics/Gynaecologists have used or recommended Chiropractic therapy. • 52.% of adult primary care clinicians and 58% of Obstetrics/Gynaecologists would like the health maintenance organisations (HMOs) to make Chiropractic available to members Mainous et al., (2000) • Design: Survey • Format: Postal questionnaire • Sampling: A random sample of 400 family physicians was selected from the American Board of Family Practice Membership and Resource Directory • Validity: Not reported Family Physicians Response rate: n = 400 questionnaires completed (39%) Results • Family physicians are much less likely than chiropractors to feel that chiropractors are primary care practitioners. • Although physicians are significantly less likely than chiropractors to feel comfortable sharing care, neither group is particularly oriented toward wanting to share care. • Physicians’ perceptions of chiropractors as an excellent source of care for some musculoskeletal problems was 2.50 but was 4.25 In response to the question that chiropractors are an excellent source of care for some nonmusculoskeletal problems (1 = strongly agree; 5 = strongly disagree) Chan and Wong (2004) • Design: Survey • Format: Postal questionnaire • Sampling: Questionnaire mailed to all physicians on list provided by Hawaii Medical Service Association (n = 1713) • Validity: Survey developed based on existing literature of national and regional surveys assessing physician knowledge attitudes and practice of CAM. Physicians Response rate: n = 299 physicians responded (17.5%) Results • Physicians reported moderate knowledge about chiropractic. • Chiropractic was perceived as therapy but not as having a role in conventional medicine Greene et al., (2006) • Design: Survey • Format: Postal questionnaire • Sampling: Survey sent to all physicians and DO's (Primary Care Physicians) in Iowa (n = 1561). • Validity: Initial pilot using a convenience sample of primary care practitioners (PCPs). Primary care practitioners (PCPs; Medical doctors (MDs) Doctors of Osteopathy (DOs)) Response rate: n = 517 responses (33%) Results • Most PCPs willing to suggest patients see a chiropractor but unwilling to formally refer with 88% preferring their patients contact chiropractors themselves. Reasons included fear of litigation, that alternative care providers may be a threat to their practice, they did not have enough knowledge or didn’t see chiropractic as a legitimate profession. • Odds of accepting referrals were 67% higher in male than female PCPs • Common reasons for referring a patient to a chiropractor were: back/neck pain, unresponsive chronic pain, fibromyalgia’s and MSK conditions. • 81% of DOs and 87% of MDs reported that their patients had asked them for information on chiropractic. • 75% of PCPs have patients who have requested a referral to a chiropractor, with 65% recommending patients to see a chiropractor. • 24% of DOs and 29% of MDs have referred a patient themselves to a chiropractor and 82.5% of DOs and 55.4% of MDs accepted referral from chiropractors. • 18% of DOs and 19% of MDs indicated chiropractors did not send them any clinical information about referred patients. • 73% sent a case report when referring a patient to a chiropractor with 77% sending follow-up clinical information for referred patients. PCPs were also more likely to send x-rays or x-ray reports and other clinical records to other PCPs rather than chiropractors. • PCPs in private practice were twice as likely to recommended patients to a chiropractor. Mullin et al., (2011) • Design: Survey • Format: Postal questionnaire • Sampling: • Email invitation was sent to 9000 email addresses of individuals with professional status as a midwife working in the United States. The questionnaire was available for 3 months and IP addresses were tracked to allow each responder to complete the survey only once. • Validity: Survey was not validated and exploratory in nature but was pilot tested with two midwives Midwives Response rate: n = 187 midwife respondents completed the questionnaire (2.1%) Results Professional training and knowledge of chiropractic • 30% indicated receiving formal training about chiropractic, 46% indicated receiving some information on chiropractic in their seminars with 75% indicating interest in learning more about chiropractic care. • 99% were aware that chiropractors work with "birthing professionals" and 92% considered themselves knowledgeable about the roles of chiropractors in prenatal care. • 40% were not aware that chiropractic was a licensed profession. • 87% wanted to see more information regarding the evidence of chiropractic management. Experience of chiropractic • 89% have had a professional experience with a chiropractor with 97% of these being a positive experience. • 92% had referred a patient to the chiropractor with 72% indicating referral to specific care of an infant. • 100% perceived chiropractic care as safe during pregnancy with 97% considering it was safe for infants. Ingram et al., (2013) • Design: Survey • Format: Post clinical experience survey • Sampling: Physical Therapy students from a south-eastern and mid-western PT program (n = 341) • Validity: Survey was reviewed by a panel of 5 directors of clinical education unaffiliated with the participating institutions. Physical Therapy students Response rate: n = 229 students competed the survey (67%) • Respondents reported that little was said about chiropractic from tutors but that clinical instructors were reported to be bad mouthing another health profession. • 61% of students heard the badmouthing occurring 2 + times. • 22% of these comments were about chiropractic and chiropractors and was one of was one of the top three most mentioned professions that were badmouthed. Bowden and Ball (2016) • Design: Survey • Format: Class administered questionnaire • Sampling: 2nd-year graduate students enrolled in either the adult Nursing or Physician Assistant programs (n = 95) • Validity: adapted version of Wong and Kopansky-Giles survey (REF) Nurse Practitioners and Physician Assistant Students Response rate: n = 92 returned questionnaires (97% Overall; 100% form PA and 94% from NPs) Results • 88% Female, majority of > 25 years of age were NPs. • Poor current level of understanding (43%); Majority indicated lack of awareness of current scientific evidence of chiropractic care (75%); Most open to learning more (63%) although 65% said they did not make effort outside of medical school to learn. • Students > 25 years of age more likely to have had experience and more likely to be positive. • 45% saw chiropractic as mainstream while 73% saw as CAM. • Participants demonstrated a wide spectrum of correct responses for types of treatment and areas where chiropractors can provide effective treatment. • Survey respondents seemed to lack knowledge that chiropractic care may constitute a range of interventions. • Respondents mostly agreed, however, that chiropractors can provide effective treatment for back pain, neck pain, headaches, shoulder pain, strain/sprain of upper and lower extremities, disc herniation, and peripheral nerve entrapment. Neff et al., (2016) • Design: Survey • Format: Questionnaire • Sampling: Sampled whole cohort (n = 116) of Physicians and Physicians Assistants working in an integrated health setting with chiropractors. • Survey underwent face validity. Physicians (Ps) and Physician Assistants (PAs) Response rate: n = 26 surveys returned (22.4%) Results: • Respondents with less knowledge and awareness of supportive research had lower opinions. PAs had a higher opinion than Ps. • Those who do refer to chiropractors have a high satisfaction with the results of the consult. • The providers who see the most patients per week seem to have the lowest opinion of chiropractic and report the least knowledge of chiropractic. Penney et al., (2016) • Design: Qualitative analysis as part on multiphase mixed methods study • Format: Interviews • Sampling: Invitation emails sent to 86 PCPs Primary Care Physicians (PCPs) Participants : 25 PCP interviews were conducted, distributed nearly evenly among PCPs who were high, medium, and low referrers for acupuncture and/or chiropractic according to plan referral records for both types of services. General comments about Chiropractic and Acupuncturists (A/C) • Generally, clinicians had little relationship therefore little communication Physicians selectively assent to patients who have had previous positive experience and didn’t want opioids. Requests denied if contraindicated via guidelines. • Many physicians believe A/C successful because of placebo so held back with patients they felt didn’t buy into CAM (however patient focus groups said they would be open even if no previous experience) • Physicians didn’t feel they knew enough about the modality or the practitioners. • Physicians expressed concern over not being able to provide patients more guidance, seemed anxious about the lack of oversight, and questioned the quality controls for ensuring patient treatment. • Variability amongst A/C providers and quality made choices difficult. Chiropractic quotes from PCPs only around communication • The near consensus from both PCPs and A/C providers was there was no effective communication. • Coupled with the negative bias in the occasional reports from patients further eroded PCP confidence in these modalities: “I’ve actually had less happiness with chiropractors the longer I’ve been in practice, just because of what I hear back from patients. […] part of it is I don’t know who I’m referring to. Because it’s this sort of contract, people that we contract with. […] I also don’t get notes back from them. So I have no feedback as to what they’re doing. Whereas all the Kaiser physical therapists put a note in [the chart]… And I can review what they’ve done, and how many times the patient has gone and the progress they’ve made or not made.” Bond et al., (2018) • Design: Survey • Format: Questionnaire • Sampling: Convenience sample across 3rd year PTs in two University programs (U! and U2). n = 144 U1 (no chiropractic faculty interaction across health care programs) and 80 at U2 (with chiropractic faculty interaction across healthcare programs) • Validity: Chiropractic attitude questionnaire (CAQ) Physical Therapy students Response rate: n = 165 questionnaires returned (74%) Results of whole cohort: Responses statistically differed between U1 and U2 : • Questions scaled from Strongly agree; Agree; Undecided; Disagree; Strongly disagree. • Chiropractic has place in health care (Highest proportion response: Agree) • Information concerning chiropractic profession should be in curriculum (Highest proportion response: Agree) • Chiropractic care is evidence based (Highest proportion response: Undecided) • Chiropractors perform excessive imaging (Highest proportion response: Undecided) • Chiropractic care is patient centred (Highest proportion response: Agree) • Manipulation of the neck is safe (Highest proportion response: Undecided) • Chiropractic is effective for non MSK (Highest proportion response: Undecided) • Chiropractic can reduce MSK load for PTs (Highest proportion response: Undecided) • Chiropractors lack training (Highest proportion response: Disagree) • Chiropractors engage in aggressive marketing (Highest proportion response: Undecided) • Chiropractors have no role in care of PT patients Highest proportion response: (Disagree) • Chiropractic care breeds dependency (Highest proportion response: Agree) Salsbury et al., (2018) • Design: Qualitative • Format: Focus groups and interviews • Sampling: Goal for participant recruitment was to invite all persons who were likely to interact with the chiropractor (patients, family and community members, administrative personnel, and members of the clinical team (medical doctors, nursing staff and therapy staff)). Qualitative analysis was part of a larger organizational case study that used ethnographic methods to explore the process of integrating a chiropractor into an established multidisciplinary team Medical doctors Nursing staff Therapy staff Participants : Sixty participants were interviewed: 48 staff members, 6 patients, 4 family members and 2 community members Study setting was a 62-bed skilled nursing facility located in north-eastern United States Themes were developed from participant responses that centred around qualities, competencies and attitudes that make a chiropractor able to work in a multidisciplinary team. These included : • Clinical acumen: to be an expert and experienced health care professional, deep understanding of musculoskeletal conditions and neurological conditions. Chiropractors should only use the therapeutic modalities that were likely to improve patients' health status. • Efficacious treatment: chiropractic care would offer effective, evidence-based options Worries that the delivery of chiropractic care to patients who have had spinal cord injuries could further injure them. • Teamwork: "We’re 95% team oriented here" • Resourcefulness: "have to be very flexible to work here ," willingness to change an approach that is not working • Openness to feedback Personality fit: "will feel comfortable educating the staff”. • Institutional compliance and mission alliance Included studies were conducted across a wide range of national settings. Study designs were substantially homogenous with a majority using cross-sectional surveys (86%). However, some studies used a range of qualitative approaches including interviews (2%), focus groups (4%) and mixed methods [survey/interview/focus groups/ combinations] (8%). A total of 10,108 participants were included across studies with a broad representation of healthcare professionals both qualified and in training, which included general practitioners (GPs), physicians, doctors, medical doctors, midwives, nurses, physiotherapists, osteopaths, and manual therapists. Results of the quality assessment generally indicated high to moderate quality (Tables 3 and 4 ). For the cross-sectional studies 33% (n = 14) fell into the high-quality category with the remaining [n = 29] were of moderate quality. Most studies scored high for research question, design, and selection of subjects, whereas sampling that allowed generalisation and sample size calculations were generally not determined. Response rates above 50% were mixed among the studies and most studies failed to provide precision (95% CI) and mitigation of potential confounders. For the 3 qualitative studies 2 were high and 1 was of moderate quality. Populations and Themes We describe the results based on broad categories of health care professionals and attitudinal/perception themes as documented below Primary Health Care Professionals (PHCPs) Studies that included PHCPs (GPs, physicians, doctors, medical doctors) were synthesised with six broad attitudinal/perception themes emerging: knowledge We arbitrarily defined 0–8, 9–16 and 17–24 as low, medium, and high-quality studies respectively. We arbitrarily defined 0–5, 6–10 and 11–16 as low, medium, and high-quality studies respectively. concerning chiropractic care or chiropractors, scope of practice, chiropractic care in health systems, interprofessional communication, research base for chiropractic care and education of chiropractors. Knowledge of chiropractic Across all included studies exploring PHCPs’ knowledge of chiropractic care or the chiropractic profession, some level of understanding was frequently reported. However, the depth of knowledge varied ranging from simply having heard about chiropractic[ 29 , 16 , 30 , 3 , 57 ] to having moderate to high levels of knowledge[ 32 , 33 , 34 ]. The most comprehensive knowledge was reported in two studies of GPs where 80% and 60% respectively of respondents had heard of or knew of the historic principals of chiropractic care [34], although it was unclear what principals had been referred to. The most frequent percentage of PHCPs possessing “some” knowledge was around 50%[ 31 , 34 ]. Some studies also reported a desire for further learning about chiropractic interventions, particularly concerning the efficacy of chiropractic care[ 31 , 29 , 74 ]. Sources by which PHCPs obtained their knowledge were documented in some studies. Most PHCPs reported obtaining their information through medical journals [ 35 , 36 ], treatment, relationship with a chiropractor, conversations with other colleagues or friends, family and media coverage [35] or patients [74]. Scope of practice : The majority of PCHPs perception of chiropractic scope recognised that care provided was beneficial in the management of musculoskeletal [MSK] or neuro-MSK disorders [ 36 , 16 , 37 , 38 , 39 ]. Studies reported PHCPs identifying specific conditions as legitimate targets of care including mechanical low back pain, neck pain, upper back pain and cervicogenic headaches [ 36 ] although MSK diagnostic skills were not always associated with perceptions of efficacy [ 37 ]. One study found that some subjects reported being in favour of regular visits to the chiropractor in the prevention of recurrent conditions [ 16 ]. Other conditions that chiropractic care was recognised to provide benefit for included: scoliosis, torticollis, growing pains, headaches, and colic, although the percentage of participants in agreement ranged widely from 20–46% across the included studies. For non -MSK conditions some PCHPs disagreed that chiropractic care was efficacious [ 74 ]. Interestingly contemporary views of some chiropractic students suggest that a tendency toward limitless scope of practice aspirations are associated with ‘magical thinking’ [ 67 ] Given that other healthcare professionals have strong views condoning a predominantly MSK focused scope of practice, and the evidence for management of non MSK conditions by chiropractors is weak or absent [ 68 ], addressing variations in chiropractic students views concerning scope of practice may be beneficial. Chiropractors in public health systems Two studies reported PHCPs agreeing that collaboration with a chiropractor, where clinically appropriate, can improve patient health and treatment outcomes [ 36 , 37 ]. White et al [ 40 ] reported that 50% of participants agreed that chiropractic care should be included in the UK National Health Service (NHS). Similar attitudes reported in a US study suggest 52% of primary care physicians and obstetrics-gynaecology physicians in a group practice model health maintenance organisation (HMO) agreed chiropractic should be available in such organisations [ 41 ]. Views differed on how chiropractic care might be integrated. Some PHCPs saw chiropractors as primary care practitioners, whilst others suggested chiropractors required referral from a medical physician to provide care within public health systems [ 32 , 16 ]. Some PHCPs perceived chiropractic care as a therapy outside conventional medicine [ 33 ], not conventional medicine [ 71 ] or expressed little interest in sharing care with chiropractors [ 39 ]. One study explored PHCPs views attributes that would be important in integrating chiropractic care into wider institutional healthcare teams [ 72 ]. These included clinical acumen, efficacious treatment, teamwork, resourcefulness, openness to feedback, personality fit, institutional compliance and mission alliance. However, attitudes and behaviour can be in conflict amongst these professionals. For example, a study of PCHPs in the UK, highlighted lack of knowledge concerning indications for use and lack of scientific evidence as a potential barrier despite chiropractic being referred to in the UK by 79% of these participants [ 73 ]. Communication between chiropractors and PHCPs A consistent theme regarding communication between PHCPs and chiropractors emerged from the included studies with PHCPs often perceiving there to be little to no effective communication [ 35 , 36 , 42 , 43 ]. Some of the underlying reasons stated were a lack of information provided by chiropractors and the use of confusing or non-standard terminology [ 35 , 42 , 43 ]. The proportions of PHCPs who had referred to or would consider referring to a chiropractor showed considerable heterogeneity across studies where reported, ranging from 2–79% of participants [ 35 , 31 , 42 , 44 , 21 , 22 , 30 , 45 , 46 ]. Whilst direct referral was the preferred route, alternative routes included informal endorsements or recommendations to patients to seek chiropractic care [ 21 , 42 ]. Motivations behind willingness to refer or recommend patients seemed to be related to knowledge of chiropractic care where PHCPs with such insights were significantly more likely to refer patients [ 35 , 47 ]. Studies further reported that patient interest was also a motivating factor, with requests from patients often being looked on as favourable reasons to consider recommendation [ 30 , 42 , 45 , 46 ]. Other motivating factors included: patients’ lack of response to conventional medicine [ 45 , 46 ], personal beliefs concerning efficacy of chiropractic care, perception of positive results for patients, high PHCP patient loads or absence/exhaustion of other options [ 47 ]. PHCPs’ attitudes and perceptions regarding referral were not equally distributed amongst demographic or practice categories. Younger doctors, who made up 67% of respondents in included studies were more likely to consider referral [ 41 ]. In a US study, PHCPs in private practice were twice as likely to recommend patients to a chiropractor than those not in private settings [ 42 ]. Direct comparison across countries was rare but in one study, PCHPs experiences of chiropractic care for their patients differed between Norwegian (66%) and Swedish (47%) clinicians reporting good experiences of chiropractic care for their patients. [ 38 ]. Factors that discouraged PHCPs referring included: a lack of knowledge of chiropractic care or absence of positive experience/relationships, as well as fear of litigation and threat to practice reputation [ 35 , 42 ]. The research base for chiropractic care Findings regarding the perceived efficacy of chiropractic care were heterogeneous. For example, Engel [ 36 ] and Grace [ 48 ] reported 21% and 66% respectively of participants disagreeing with the notion that there was a growing body of evidence supporting the efficacy of chiropractic approaches to care despite these studies being published at a similar time. Other surveys reported positivity regarding evidence for effectiveness where PCHPs considered chiropractic practice to be generally primarily evidence based [ 36 , 31 ]. However, the proportion of respondents aligning to this view varied considerably (12–70%) [ 48, 22, 30, 45, 46]. Views concerning perceived adverse effects and/or potential harm were also heterogenic. White et al [ 40 ] Pirotta [ 30 ] and Grace [ 48 ] reporting 13%, 38% and 75% of participants respectively showing concern that chiropractic care maybe occasionally harmful. This also varied across national settings where US based orthopaedic surgeons were more likely to feel that neck manipulation was safe in comparison to their Canadian colleagues [ 57 ] Chiropractic education and skills There were mixed opinions regarding perceptions related to chiropractic education and skills. Negative perceptions included Grace [ 48 ] where one quarter of respondents were concerned about the credibility of the educational background of chiropractors, whilst Engel [ 36 ] reported 70% of PHCPs believing that chiropractic education was not primarily evidence based. More positively, Westin [ 38 ] found that 80% of their Scandinavian study PCHPs agreed that the education of chiropractors was satisfactory while Canadian orthopaedic surgeons felt chiropractors had adequate education [ 57 ]. Non-Medical Health Care Professionals (NMHPs) Studies exploring attitudes and perceptions of NMHPs included midwives, nurses, physiotherapists, osteopaths, and manual therapists. Similar themes ( knowledge concerning chiropractic care or chiropractors , chiropractic care in health systems and the education of chiropractors ) emerged as for PCHPs apart from scope of practice, research base and interprofessional communication which were largely absent. Knowledge of chiropractic Studies included reported midwives, osteopaths, physiotherapists, and manual therapists had some knowledge of chiropractic. Langworthy [ 49 ] noted that two thirds of osteopaths, manual therapists and physiotherapists had heard something about chiropractic. In midwifery there were high levels of knowledge reported where 98% were aware that chiropractors work with midwives, 92% considered themselves knowledgeable of the role of chiropractic within prenatal care, 59% knew that the chiropractic profession was a licensed profession and 75% showed interest in learning more about the profession [ 50 ]. Sources of information used by NMHPs to gain knowledge of chiropractic were heterogenic. For example, formal education as to the role of chiropractic in healthcare varied from 10% of physiotherapists, 25–33% of manual therapists and osteopaths and 30% of midwives [ 49 , 50 ]. In addition, one third of physiotherapists, osteopaths and manual therapists gained their knowledge through talking to their own patients. Furthermore, despite being the least preferred method of learning, 20% of physiotherapists and osteopaths obtained information from media outlets with the preferred method through scientific journals [ 49 ]. Finally, 46% of midwives in one study also received information from attending seminars [ 50 ]. Views concerning the efficacy and safety of chiropractic care was explored amongst midwives and nurses. For the midwifery study, 100% of participants agreed that chiropractic is safe during pregnancy and 96% agreed that chiropractic is also safe for infant care, although, responder bias may be significant here due to very low response rate [ 50 ]. Chiropractic in public healthcare systems Views concerning inclusion in healthcare systems included perceiving the chiropractic profession as direct competition, with half perceiving the profession to be best described as a complementary alternative therapy. These respondents were generally unsupportive of statutory registration for the profession, but this was over 2 decades ago [ 49 ]. More positively, most physiotherapists, osteopaths and manual therapists agreed that better communication and collaboration between professionals would likely be better for patient care [ 49 ]. Interestingly in the single study concerning midwifery, 88.8% of respondents reported having worked with chiropractors professionally with 97% of this cohort reporting a positive experience. Ninety two percent of this cohort also reported having referred to chiropractors for infant care [ 50 ]. However, the return rate for the survey was only 2.1% with responder bias likely to be significant. Chiropractic education and skills A single study reported that 50% of physiotherapists and 100% of osteopaths felt chiropractors were skilled professionals [ 49 ]. Primary health care students (PHCS) Studies concerning attitudes and perceptions of PHCS identified a single common theme centered on lack of knowledge of current chiropractic care. Respondents included 1,200 medical students from UK, Australia, and Canada in 4 separate studies. Here the primary theme was around knowledge concerning chiropractic care or chiropractors . Knowledge of chiropractic Most participants indicated poor knowledge and understanding of chiropractic care [ 34 , 52 ]. Perkin [ 34 ] compared GPs, medical doctors and medical students and reported that GPs were statistically more knowledgeable than both MDs and medical students, with medical students being the least knowledgeable. In one study, sources of knowledge for PHCS were from informal sources such as conversations with friends, small groups, student clubs and lecturers [ 52 ]. Some participants noted these experiences often painted a negative impression of chiropractic with most participants unable to recall positive descriptions concerning chiropractic by academic staff. This study further explored PHCS perceived knowledge of a chiropractors’ scope of practice, and showed half of medical students surveyed were undecided or had no knowledge, associated with apprehension concerning referring. When asked about how medical students perceived chiropractic care within the healthcare landscape, 61.6% of participants perceived chiropractic as a CAM profession [ 52 ]. Despite most participants having limited knowledge of chiropractic care, interest in learning more was expressed by 67% of participants. These students expressed particular interest in learning what conditions chiropractors commonly treat, with 83.9% agreeing that interprofessional education is important [ 52 ]. In an Australian study by Hopper et al [ 53 ], 84% of respondents indicated chiropractors should be on a professional register whilst only 48% felt they should be remunerated through the national system. Non-Medical healthcare students (NMHCS) Respondents in this cohort included students in various years of their education studying nursing [ 54 ] or physiotherapy/physical therapy [ 55 , 56 ]. Common themes emerged as in other cohorts including knowledge concerning chiropractic care or chiropractors , chiropractic in public healthcare systems, chiropractic education a skills and the chiropractic research base Knowledge of chiropractic The knowledge students possessed concerning chiropractic care showed heterogeneity across studies. Amongst physiotherapy students in South Africa in 1st and final years, 58% and 62% respectively showed a good level of knowledge [ 56 ]. In contrast, within this same cohort, 38% of 1st year students and 49% final year students thought “chiropractors do the same thing as physios.” In contrast nursing students showed a poor level of understanding of the profession despite recognising a chiropractor’s scope of practice as regularly treating patients with back pain, neck pain, headaches, shoulder pain, strain/sprain of extremities, disc herniations, and peripheral nerve entrapments [ 54 ]. When asked about interest in learning about the profession, 65% responded that they wouldn’t try to learn outside of school, with most students having no personal interest in learning about chiropractic care. In contrast, when physiotherapy students were asked about their interest towards learning about the profession, 55.3% agreed that chiropractic information should be in the curriculum [ 55 ]. Chiropractic in public healthcare systems Questions regarding chiropractic care as delivered within the wider public health system were explored in some studies with 60.3% of physical therapy students agreeing that chiropractic has a place in healthcare [ 54 ]. Where chiropractors and physiotherapists attitudes towards each other were explored, 76% of 1st year physiotherapy students and 84% of final year students perceived chiropractors as direct competition, with some believing chiropractors delivered similar care to physiotherapists. Interestingly as these students progressed through undergraduate education, interest in referring to chiropractors decreased. Moreover, and somewhat contradictory, 43% of 1st year students and 53% final year students were happy to work closely with chiropractors in patient care [ 56 ]. Generally, attitudes concerning chiropractic care as integrated into wider healthcare systems showed considerable variation with students seeing chiropractic as a complementary or alternative medicine or mainstream [ 54 ]. Research base for chiropractic care Evidence for chiropractic care emerged as an issue for physical therapy students where 46.3% were undecided as to whether chiropractic is evidence-based and 47.8% were undecided that chiropractic can provide effective care for non-MSK patients [ 55 ]. In exploring other perceptions, 38.2% of the same cohort believed that manipulation of the neck is generally safe, and 43.4% were undecided whether chiropractic care bred patient dependency. However, a somewhat contradictory 57.1% of respondents felt chiropractors provide patient-centered care leading. In contrast, Naidoo and Buhler [ 56 ] found 25% and 50% of 1st and final year students respectively, who have had previously consulted a chiropractor, agreed that chiropractic care was effective. Nursing students reported a lack of awareness of the scientific evidence on chiropractic care [ 54 ]. Overall, considerable variation and potential cognitive dissonance may exist amongst these cohorts Chiropractic education and skills Education and training of chiropractors was briefly mentioned in the study conducted by Bond et al [ 55 ] where only 7% of physical therapy students agreed with the proposition that chiropractors lack sufficient training. Interestingly a single study explored unconscious attitudes and perceptions amongst non-medical students using an implicit association test. Here a list of words identified in a survey of physiotherapy students that best described chiropractic or medicine as determined by these students was subsequently used in a word association test with negative or positive terms. The authors reported that the word association task took statistically significantly longer to complete when “chiropractic” was paired together with “positive” terms than when “chiropractic” was paired together with “negative” terms uncovering potential subconscious negative bias toward chiropractic [ 64 ] Secondary analysis over time within countries There was considerable heterogeneity of samples, professions and survey instruments between national settings and over time, although research designs were generally homogeneous. We attempted to identify any trends over time by grouping studies by national jurisdiction to mitigate differences in cultural, fiscal, and legislative settings. Table 5 shows summary comments within each country and where only one study exists a general comment summarizing the study is made. Although there are limitations to this approach, we identified a general absence of overt positive change in attitudes and perceptions over time in countries with more than one study. Indeed, where trends could be robustly identified via repetition of the same survey, either negative sentiment and perceptions remained [ 57 , 58 ] or attitudes and cooperation worsened [ 21 , 22 ]. Consistent themes emerged over time around a continued lack of knowledge concerning chiropractic practice, education, and scientific evidence, particularly amongst medical personnel. Generally, (although with exceptions) the literature reviewed here suggest referrals between most chiropractors and medical doctors in most national jurisdictions remains low and that has persisted over time. Importantly, where good relationships within clinical or educational institutions were present or amongst individual health care professionals and chiropractors, there was evidence of increased positivity and cooperation. In addition, where greater knowledge was present this was also often associated with more positive attitudes. Discussion This review has summarised the published data concerning attitudes and perceptions of a wide range of health care professionals and health care students toward chiropractors and chiropractic care. Major themes regarding knowledge concerning chiropractic care or chiropractors, scope of practice, chiropractic in public healthcare systems, interprofessional communication, the research base for chiropractic care , and the education of chiropractors emerged. These themes appeared in varying degrees across all groups surveyed but not all themes were present in every group. Not surprisingly those professions more closely aligned to the scope of practice commonly associated with chiropractors [musculoskeletal] tended to have more knowledge and broadly more acceptance [ 49 ], whereas participants with limited contact with chiropractors or chiropractic patients were less informed [ 52 , 53 ]. Positively, perception of the potential harm associated with chiropractic care appears to have reduced over time. However, some themes have persisted and may be impacted by a lack of consistent and accurate information about chiropractic in the minds of participants. For example, lack of knowledge amongst PHCPs in included studies for example, appears to be related to a general lack of working together despite clinicians often expressing the importance of collaboration [ 37 , 49 , 59 ] However, where other health professionals came into contact with chiropractors within their day-to-day work, attitudes shifted positively. [ 51 ]. Concerning evidence, Neff [ 70 ] reported that physicians and physician-assistants that had lower knowledge of supportive research for chiropractic care, also had lower opinions of the profession generally, so a paucity of knowledge here also may have important implications for attitudes and perceptions more widely. Doubts concerning the adequacy of chiropractic education also appears to have persisted [ 55 , 37 , 29 ] although in one study such doubts differed for chiropractors graduating from different institutions. For example, those graduating from an institution in the USA being perceived as far less adequate than those from a chiropractic program in Canada [ 29 ]. In non-medical healthcare participants similar themes arose but in physiotherapists, added to perceived competition [ 56 ]. These professionals often had good knowledge of the chiropractic profession although the sources of this knowledge were diverse and did not include the chiropractic profession themselves. Despite some studies reporting lack of support of chiropractors working within the health systems, generally there was consensus around cooperation and multi-professional patient management. Attitudes and perceptions were however somewhat malleable, where more positive attitudes seemed to be generated post an educational intervention shifted attitudes toward the positive [ 59 ]. Here, after the intervention there was a statistically significant increase in number of attitude-positive responses compared to the prequestionnaire. The authors conclude that formal education within medical curricula may help to mitigate hidden curriculum issues and support collaboration between medical and chiropractic providers post-graduation. Suboptimal communication between chiropractors and other health care professionals stood out as a particular factor with achievable solutions. Lack of sufficient information about referred patients provided by chiropractors was cited as a problem in some studies [ 35 , 38 ]. Another element related to communication was chiropractors’ use of confusing or non-standard terminology [ 35 , 38 ]. These factors have been explored in both Australia and the UK with evidence of a continued prevalence of chiropractic specific terminology on the chiropractors’ websites [ 75 , 76 ] An increase in better communication might usefully be addressed education settings, as well as in guidelines from regulators. Professional identity has long been debated within the chiropractic profession [ 1 , 2 , 3 , 5 , 6 , 7 , 8 , 23 , 65 , 66 ]. Some chiropractors see themselves as primary care [ 60 , 61 ], but this review demonstrates that many physicians do not consider them so. Here, educational interventions for other health care professionals including integrating knowledge of chiropractic care within curricula of medical and non-medical health care professionals may prove useful. Healthcare students identified fewer, but similar themes centring predominantly on a lack of knowledge of the profession, particularly in medical students with sources of knowledge ranging from anectodical conversations amongst students themselves to medical faculty, who were perceived as generally less than positive [ 62 ]. Despite this there was a desire to learn more in addition to support for interprofessional cooperation. [ 54 ] The implications for the chiropractic profession of the insights provided by this literature review ultimately rests on where the profession desires to go, how it aspires to be identified and in what capacity it wishes the existing healthcare community to understand and interact with chiropractors. It is not disputed that interprofessional communication and working relationships between health care professionals for the benefit of their mutual patients is both desired by patients and increases the likelihood of higher satisfaction and better outcomes [ 21 , 75 ]. Further research would usefully explore the attitudes and aspirations of the chiropractic profession in this regard. For example, the profession as a community may feel they do not desire to work in the wider healthcare landscape having curated successful practices at least financially, without having to do so. Such isolation was impacted early on in chiropractic history through sustained persecution by the medical profession in the US where to be ‘ separate and distinct to medicine’ had kept early chiropractors out of jail. However, these times have passed, and the continued isolation of the profession has been contemporarily paraphrased as ‘ separate and extinct’. Perhaps such desires from a vocal part of the profession to cleave to this separateness may not be sustainable in the long term. On the other hand, if a majority desire to forge better and more cohesive relationships with other health care professionals, this review suggests educational interventions may be particularly efficacious in underpinning increased knowledge and a willingness to work toward mutual support of their patient communities. This particularly so at undergraduate level where perhaps interprofessional learning in joint classrooms may facilitate a learn together, work together mindset. Clearly however there must be willingness from both sides to corporate better. Where such models exist, they may constitute general exemplars of structures and cultures where this works [ 80 ]. Strengths This review is, as far as we know, the first to comprehensively review the large number of studies that have surveyed other professions as to attitudes and perceptions of chiropractic care and chiropractors. We chose to not limit the date which meant we were able to explore any changes of attitude over long periods, particularly where identical surveys were repeated at different time point in some jurisdictions, although this was limited by several factors as discussed below. Limitations There are clear limitations to this review. Firstly, we chose not to limit the period of the publications which resulted in a large time window within which the results were available where issues initially present in older studies may have been mitigated in more recent surveys. Our attempt to explore changes in perceptions over time was clearly limited by study heterogeneity form one study to the next, except in just a few cases where surveys were repeated by the same authors. Survey instruments were also heterogenic although most had attempted some degree of face validity or had created surveys based on previous literature. However, the degree with which detail concerning attitudes could be extracted was varied with one study providing only a single question concerning attitudes regarding the chiropractic profession [ 63 ]. Notwithstanding, such heterogeneity in the wording and design of surveys, and within national jurisdictions would suggest caution in interpreting any observed similarities or differences between studies results. In addition, only a third of studies were deemed high quality as judged by the risk of bias assessment in the review with the remaining two thirds being medium quality. In the absence of a sub analysis based on quality, the reporting of high and medium quality studies as a homogenous group may have confounded attempts to summarise themes. Lastly, not all national jurisdictions were represented equally with Australia, Canada, USA and UK dominating the data set. We attempted to mitigate this by presenting characteristics of studies within national jurisdictions and summarising any observed changes within these jurisdictions over time. However, this observational summary may not be as robustly representative as desired to confidently identify changes. Conclusion The results of this review suggest that a consistent issue impacting attitudes and perceptions of other professions toward chiropractic care or chiropractors is a general lack of knowledge concerning key aspects of the chiropractic profession. Where knowledge was higher, generally attitudes and perceptions were more positive and where educational interventions were used to increase knowledge such efforts generated improved perceptions. The solution to this knowledge gap may be multifactorial and include efforts to produce accessible and digestible quality information concerning the themes highlighted in this review and/or greater visibility of the chiropractic profession within diverse healthcare settings or through greater shared management of patients. Declarations Ethics approval and consent to participate. Not applicable Consent for publication. Not applicable Availability of data and materials Data sharing not applicable to this article as no datasets were generated or analysed during the current study. Competing interests The authors declare that they have no competing interests. Funding This study was funded by a grant from the Chiropractic Research Council, UK. The funder had no role in the design of the study, analysis, interpretation of data and in writing the manuscript. Authors' contributions DN designed the study and conducted scoping searches. AN and DN completed all searches whilst AN, KY and JF applied the exclusion/inclusion criteria with AN and DN assessing quality and risk of bias. AN, DN, MH and MS completed the draft manuscripts whilst all authors contributed to the final text and approved the manuscript for submission. Acknowledgements Not applicable References Reggars JW (2011) Chiropractic at the crossroads or are we just going around in circles? Chiropr Man Th 19:11 Meeker WC, Haldeman S (2002) Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 136(3):216–227 Walker BF (2016) The new chiropractic. Chiropr Man Th 24:26 Johnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D (2008) Chiropractic and public health: Current state and future vision. J Manip Physiol Ther 31:397–410 Pollard H (2021) Reframing a debate in chiropractic. Chiropr Man Th 29:44 McGregor M, Puhl AA, Reinhart C, Injeyan HS, Soave D (2014) Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey. BMC Complement Altern Med 14:51 Gliedt JA et al (2021) Evaluation of United States chiropractic professional subgroups: A survey of randomly sampled chiropractors. BMC Health Serv Res 21(1):1–1049 Gíslason HF, Salminen JK, Sandhaugen L, Storbråten AS, Versloot R, Roug I, Newell D (2019) The shape of chiropractic in Europe: A cross-sectional survey of chiropractor’s beliefs and practice. Chiropr Man Th 27:16 Stochkendahl MJ, Rezai M, Torres P, Sutton D, Tuchin P, Brown R, Côté P (2019) The chiropractic workforce: a global review. Chiropr Man Th 27:1–9 HCPC [2021] (2022) Which professions do HCPC regulate? Health & Care Professions Council. Available at: https://www.hcpc-uk.org/public/which-professions-do-hcpc-regulate/ Accessed November 30 NHS England. The 14 allied health professions. London: NHS (2022) Available from: https://www.england.nhs.uk/ahp/role/ Reiter HH (1965) Some physicians’ perceptions of chiropractors, osteopaths, and podiatrists. Percept Mot Skills 20(3suppl):1167. 8.https://doi.org/10.2466/pms.1965.20.3c.1167 Toloui-Wallace J, Forbes R, Thomson OP, Setchell J (2022) When worlds collide: Experiences of physiotherapists, chiropractors, and osteopaths working together. Musculoskelet Sci Pract. ;60 O’Neill SF, Konner MB, Fejer R, Vesterager SV (2020) Establishing a residency program for a chiropractic specialty in a public hospital system: Experiences from Denmark. J Chiropr Educ 34(2):164–171 Burdick R, Corcoran KL, Zhao X et al (2022) The rate of use of Veterans Affairs chiropractic care: a 5-year analysis. Chiropr Man Th. ;30(4) Louwe J, Myburgh C (2007) The knowledge and perception of general practitioners about chiropractic as a factor that may influence inter-professional communication: a South African perspective. J Interprof Care 21(2):221–224 National Board of Chiropractic Examiners. Practice analysis of chiropractic 2020. Greeley (CO): NBCE (2020) Available from: MyNBCE - The Practice Analysis of Chiropractic 2020 Jørgensen P (2014) Kiropraktikkens historie i Danmark. Syddansk Universitetsforlag, Odense, pp 195–248 Myburgh C (2014) A qualitative exploration of key informant perspectives regarding the nature and impact of contemporary legislation on professional development: a grounded theory study of chiropractic in Denmark. J Manipulative Physiol Ther 37(6):383–395 General Chiropractic Council (2021) Registrant Survey 2020 – Main Report. Available from: https://www.gcc-uk.org/assets/publications/GCC_Registrant_Survey_2020_-_main_report_final.pdf Perry R, Dowrick CF (2000) Complementary medicine and general practice: an urban perspective. Complement Ther Med 8(2):71–75 Perry R, Dowrick C, Ernst E (2014) Complementary medicine and general practice in an urban setting: a decade on. Prim Health Care Res Dev 15(3):262–267 Simpson JK, Young KJ (2020) Vitalism in contemporary chiropractic: a help or a hinderance? Chiropr Man Th 28:35. 10.1186/s12998-020-00307-8 Centre for Evidenced Based Management Critical Appraisal of a Survey. Available at this link https://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-July-2014-1-v2.pdf [Accessed March 2021] Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N, Roen K, Duffy S (2006) Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme. Lancaster University, Lancaster. https://doi.org/10.13140/2.1.1018.4643 Centre for Evidenced Based Management Critical Appraisal of a Survey. Available at this link https://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-July-2014-1-v2.pdf [Accessed March 2021] Centre for Evidence Based Medicine Critical Appraisal Qualitative. Available at this link https://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Qualitative-Study-July-2014-1-v2.pdf [Accessed March 2021] Thondhlana SS, Kell CM, Pillay JD (2021) General practitioners’ knowledge, perception and utilization of services in the chiropractic management of musculoskeletal disorders in Harare, Zimbabwe. Afr J Phys Activity Health Sci 27(1):72 Busse JW, Jim J, Jacobs C, Ngo T, Rodine R, Torrance D, Kulkarni AV, Petrisor B, Drew B, Bhandari M (2011) Attitudes towards chiropractic: an analysis of written comments from a survey of North American orthopaedic surgeons. Chiropr Man Th 19(1):1–7 Pirotta MV, Farish SJ, Cohen MM, Kotsirilos V (2000) Complementary therapies: have they become accepted in general practice? Med J Aust 172(3):105–109 Davidson E (2007) Experience with and attitudes towards chiropractors treating children among GPs in Grampian, Scotland—a survey. Focus Altern Complement Ther 12:18 Preston-Thomas A, Van den Bergh LA, Maxwell L (1993) Referral for Manual Therapy: A Survey Of General Medical Practitioners In The Auckland Area. N Z J Physiother 21:25–28 Chan PS, Wong MM (2004) Physicians and complementary-alternative medicine: training, attitudes, and practices in Hawaii. Hawaii Med J. ;63(6) Perkin MR, Pearcy RM, Fraser JS (1994) A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine. J R Soc Med 87(9):523–525 Brussee WJ, Assendelft WJ, Breen AC (2001) Communication between general practitioners and chiropractors. J Manip Physiol Ther 24(1):12–16 Engel RM, Beirman R, Grace S (2016) An indication of current views of Australian general practitioners towards chiropractic and osteopathy: A cross sectional study. Chiropr Man Th 24:1–0 Newton-Leo L, King-Isaacs D, Lichti J (1994) Knowledge and opinions of Downsview physicians regarding the chiropractic profession. J Can Chiropr Assoc 38(2):90–95 Westin D, Tandberg T, John C, Axén I (2013) GPs opinions and perceptions of chiropractic in Sweden and Norway: a descriptive survey. Chiropr Man Th 21:1–7 Mainous AG 3rd, Gill JM, Zoller JS, Wolman MG (2000) Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med 9(5):446–450 White AR, Resch KL, Ernst E (1997) Complementary medicine: use and attitudes among GPs. Fam Pract 14(4):302–306 Gordon NP, Sobel DS, Tarazona EZ (1998) Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization. West J Med 169(3):153 Greene BR, Smith M, Allareddy V, Haas M (2006) Referral patterns and attitudes of primary care physicians towards chiropractors. BMC Complement Altern Med 6(1):1–1 Penney LS, Ritenbaugh C, Elder C, Schneider J, Deyo RA, DeBar LL (2016) Primary care physicians, acupuncture and chiropractic clinicians, and chronic pain patients: a qualitative analysis of communication and care coordination patterns. BMC Complement Altern Med 16:1 Kier A, George M, McCarthy PW (2013) Survey based investigation into general practitioner referral patterns for spinal manipulative therapy. Chiropr Man Th 21(1):18 Verhoef MJ, Sutherland LR (1995) Alternative medicine and general practitioners: Opinions and behaviour. Can Fam Physician 41:105–1011 Verhoef MJ, Page SA (1996) Physicians’ perspectives on chiropractic treatment. J Can Chiropr Assoc. ;40(4) Wardle JL, Sibbritt DW, Adams J (2013) Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia. Chiropr Man Th 21:1–9 Grace S, Engel R, Jalsion I (2018) Themes underlying Australian general practitioner views towards chiropractic and osteopathy: An assessment of free text data from a cross-sectional survey. Evidence-Based Complementary and Alternative Medicine . ;2018 Langworthy JM, Smink RD (2000) Chiropractic through the eyes of physiotherapists, manual therapists, and osteopaths in The Netherlands. J Altern Complement Med 6(5):437–443 Mullin L, Alcantara J, Barton D, Dever L (2011) Attitudes and views on chiropractic: a survey of United States midwives. Complement Ther Clin Pract 17(3):13540 Garner MJ, Birmingham M, Aker P, Moher D, Balon J, Keenan D, Manga P (2008) Developing integrative primary healthcare delivery: Adding a chiropractor to the team. Explore 4(1):18–24 Wong JJ, Di Loreto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles D (2013) Assessing the attitudes, knowledge, and perspectives of medical students to chiropractic. J Can Chiropr Assoc 57(1):18 Hopper I, Cohen M (1998) Complementary therapies and the medical profession: A study of medical students’ attitudes. Altern Ther Health Med 4(3):68–73 Bowden BS, Ball L (2016) Nurse practitioner and physician assistant students’ knowledge, attitudes, and perspectives of chiropractic. J Chiropr Educ 30(2):114–120 Bond BM, Dehan J, Horacek M (2018) Does interprofessional interaction influence physical therapy students’ attitudes toward chiropractic? J Can Chiropr Assoc 62(3):143 Naidoo N, Bühler L (2009) The perceptions, attitudes and knowledge of physiotherapy and chiropractic students regarding each other’s professional practice. S Afr JPhysiother 65(2):32–37 Busse JW, Jacobs C, Ngo T, Rodine R, Torrance D, Jim J, Kulkarni AV, Petrisor B, Drew B, Bhandari M (2009) Attitudes toward chiropractic: a survey of North American orthopedic surgeons. Spine 34(25):2818–2825 Busse JW, Pallapothu S, Vinh B, Lee V, Abril L, Canga A, Riva JJ, Viggiani D, Dilauro M, Harvey MP, Pagé I, Bhela AK, Sandhu S, Makanjuola O, Hassan MT, Moore A, Gauthier CA, Price DJ (2021) Attitudes towards chiropractic: a repeated cross sectional survey of Canadian family physicians. BMC Fam Pract Wong JJ, Di Loreto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles D (2014) Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after an educational intervention. J Chiropr Educ 28(2):112–122 Hunnisett A, Cunliffe C (2012) Chiropractic treatment as a primary care intervention for better musculoskeletal health in the aging population in the United kingdom: an opinion and positioning paper. Front Physiol 3:87 Jones-Harris AR (2010) Are chiropractors in the uk primary healthcare or primary contact practitioners? a mixed methods study. Chiropr Man Th 18:28 Ingram D, Flom-Meland C, Hosford C, Grubb R, Nicholson CC, Terry B (2013) Badmouthing of health care professionals. J Phys Therapy Educ 27(2):16–22 Živčić D, Racz A, Naletilić D (2014) Differences in attitudes towards/beliefs on complementary and alternative medicine witnessed between physiotherapists, nurses, paramedics, and physicians. Afr J Tradit Complement Altern Med 11(6):57–65 Chung CL, Manga J, McGregor M, Michailidis C, Stavros D, Woodhouse LJ (2012) Interprofessional collaboration and turf wars: how prevalent are hiddenattitudes? J Chiropr Educ 26(1):3 de Luca K et al (2018) The identity, role, setting, and future of chiropractic practice: A survey of Australian and New Zealand chiropractic students. JChiropractic Educ Glucina TT et al (2020) Moving towards a contemporary chiropractic professionalidentity. Complementary Therapies in Clinical Practice Innes S, Goncalves G, Leboeuf-Yde C (2022) Who are the chiropractic students favouring a limitless scope of practice? Exploring the relationship with personality, magical thinking, and academic achievement. Chiropr Man Th 30:30 Côté P, Hartvigsen J, Axén I et al (2021) The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature. Chiropr Man Th 29:8 Kvammen OC, Leboeuf-Yde C (2014) The chiropractic profession in Norway 2011. Chiropr Man Th 22:44. https://doi.org/10.1186/s12998-014-0044-5 Neff S, DC M, Jordan RJ (2016) Physician & Physician Assistant Attitudes and Referral Habits Concerning Chiropractic. J Acad Chiropr Orthop 13(2):1–11 Poynton L, Dowell A, Dew K, Egan T (2006) General practitioners’ attitudes toward [and use of] complementary and alternative medicine: a New Zealand nationwide survey. N Z Med J 119(1247):U2360 Salsbury SA, Vining RD, Gosselin D, Goertz CM (2018) Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team. Chiropr Man Th 26:29 Schmidt K, Jacobs PA, Barton A (2002) Cross-cultural differences in GPs’ attitudes towards complementary and alternative medicine: a survey comparing regions of the UK and Germany. Complement Ther Med 10(3):141–147 Weis CA, Stuber K, Barrett J, Greco A, Kipershlak A, Glenn T, Desjardins R, Nash J, Busse J (2016) Attitudes toward chiropractic: a survey of Canadian obstetricians. J Evid Based Complement Altern Med 21(2):92–104 Young KJ (2020) Words matter: the prevalence of chiropractic-specific terminology on Australian chiropractors’ websites. Chiropr Man Th 28:18 Young KJ, Theroux J (2021) Prevalence of Chiropractic-Specific Terminology on Chiropractors’ Websites in the United Kingdom with Comparison to Australia: An Analysis of Samples. J Chiropr Humanit 28:15–21 Humphreys BK, Peterson CK, Muehlemann D, Haueter P (2010) Are Swiss chiropractors different than other chiropractors? Results of the job analysis survey. J Manipulative Physiol Ther 33(7):519–535 Humphreys BK, Peterson CK (2016) The Swiss Master in Chiropractic Medicine Curriculum: Preparing Graduates to Work Together With Medicine to Improve Patient Care. J Chiropr Humanit 11(1):53–60 Schot E, Tummers L, Noordegraaf M (2020) Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. J Interprof Care 34(3):332–342 Hofstetter L, Häusler M, Mühlemann M et al (2022) Musculoskeletal healthcare at a Swiss university hospital chiropractic medicine outpatient clinic in 2019: a health services research study. Chiropr Man Th ;30 (7) Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71 Tables Tables 3 and 4 are available in the Supplementary Files section Additional Declarations The authors declare no competing interests. Supplementary Files Table34.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5803290","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":400443412,"identity":"09a64437-7cfd-4924-be20-5deab8dc2613","order_by":0,"name":"Dave Newell","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYDCCAyCiwEIOIcJDlBYDCWPStSQ2EK2F73bzMYkPBhLp/e3NDz8w1NgxGJw5gF+L5J1jaZIzDCRyZ5w5ZizBcCyZweBsA34tBjdyzG7zALU03MhhY2BgO8BgcJ6Awwxu5H+7/QfoMPn7b4Ba/hGlJYftNtD7CQY3eNgYGNsOEHaY5I008589BhKGG8+kGUsk9iXzSBLyPt+N5McGPyps5OWOH3744cM3Ozm+MwkEXIYCEoiIyFEwCkbBKBgFRAAASN9CzzJTdDYAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-1462-3586","institution":"Health Sciences University","correspondingAuthor":true,"prefix":"","firstName":"Dave","middleName":"","lastName":"Newell","suffix":""},{"id":400443623,"identity":"00b416fb-ccdf-4fdb-9914-e3df8483e1bd","order_by":1,"name":"Amin Nouroozi","email":"","orcid":"","institution":"Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Amin","middleName":"","lastName":"Nouroozi","suffix":""},{"id":400444411,"identity":"c091da7a-2dab-4028-a509-d839d7b4c382","order_by":2,"name":"Marc Sanders","email":"","orcid":"","institution":"University of Southampton","correspondingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Sanders","suffix":""},{"id":400444412,"identity":"d2ec69cf-0abf-4bae-a98c-1e2176062c2d","order_by":3,"name":"Jonathan Field","email":"","orcid":"","institution":"NHS","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Field","suffix":""},{"id":400444413,"identity":"3316338c-e956-4c92-81b9-4af2cdf21a5c","order_by":4,"name":"Kenneth Young","email":"","orcid":"","institution":"University of Central Lancashire","correspondingAuthor":false,"prefix":"","firstName":"Kenneth","middleName":"","lastName":"Young","suffix":""},{"id":400444414,"identity":"a6b8d8d0-aee0-47d4-897e-4147dbc41c27","order_by":5,"name":"Michelle Holmes","email":"","orcid":"","institution":"Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Holmes","suffix":""}],"badges":[],"createdAt":"2025-01-10 11:25:38","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5803290/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5803290/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73676724,"identity":"d5aaa1be-09c8-471b-a85d-a75bae94f0da","added_by":"auto","created_at":"2025-01-13 13:11:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41161,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Selection flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5803290/v1/8ef3f9e96e38b69ec8e1f400.png"},{"id":73678362,"identity":"59f22371-7aba-4a71-ba82-293113df6d64","added_by":"auto","created_at":"2025-01-13 13:27:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2539107,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5803290/v1/92481328-4584-4b3d-a4dc-4bcbaf4f37af.pdf"},{"id":73676725,"identity":"6299ee07-89e3-4e24-acb5-73211623e67c","added_by":"auto","created_at":"2025-01-13 13:11:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":51948,"visible":true,"origin":"","legend":"","description":"","filename":"Table34.docx","url":"https://assets-eu.researchsquare.com/files/rs-5803290/v1/06c2fec5b8d7f17c1f2c8e68.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAttitudes and perceptions of health care professionals concerning chiropractors and chiropractic practice: A Systematic Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe chiropractic profession has found itself at self-identified crossroads several times. Such crossroads appear to highlight similar choices [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] which dichotomise into approaches to practice that embrace expectations and norms within contemporary healthcare or one that sits outside of these norms as separate and distinct. This latter option is generally associated with a historical and non-evidenced ideology in opposition to accepted guidelines and best practice [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Such polarised professional discourse continues to occupy significant time and effort despite such views constituting a minority of the profession [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn many jurisdictions across the world, chiropractic care remains outside of national health systems [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the UK for example chiropractors, uniquely amongst legally registered health care professions, are not considered to be part of the national recognised healthcare work force [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Globally, it is typically uncommon for chiropractors to work in multidisciplinary practice or in hospitals, although there are exceptions. These are often pioneered by individual chiropractors who have forged relationships and opportunities with partnerships across the healthcare landscape [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. In some countries, chiropractors have made inroads into national health systems; in the United States in 2019 approximately 15% of chiropractors reported working within an integrated healthcare facility with over 5% holding hospital staff privileges [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In other examples, such as in some Nordic countries and Switzerland, the chiropractic profession has been more successful in its acceptance as part of healthcare systems [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. In Denmark for example, over 90% of chiropractors in private practice are partially funded by government subsidy, whilst a smaller number (approximately 5%) practice in private or public hospital settings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Conversely, a UK survey in 2021 showed a decline in chiropractors working within the NHS, from 18% in 2002 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] to just 2% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe persistent exclusion of chiropractic from many national healthcare systems raises the question of why this remains the case after over a century of chiropractic care. One speculative reason may be the adherence by a minority of the profession to outdated dogma [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This, combined with possibly justified and/or unjustified negative perceptions from other healthcare practitioners who act as gatekeepers to healthcare systems, may hinder the profession's acceptance and integration. These attitudes can also impede contemporary patient-centred paradigms that favour interprofessional collaboration, which is increasingly encouraged and preferred by patients. The exclusion of chiropractors from these practices could limit patient access to diverse, appropriate care and negatively impact patient experiences and outcomes.\u003c/p\u003e \u003cp\u003eTherefore, this review aims to explore the existing literature to understand the perceptions and attitudes of other healthcare professionals towards chiropractors and chiropractic practice.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e This systematic review has been written up in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.[\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLiterature Search\u003c/h2\u003e \u003cp\u003e An initial scoping search was conducted in 2021 to refine the research question and construct the full review protocol which was published on PROSPERO (CRD42023403381). A detailed search strategy was developed and derivatives and synonyms of key terms describing non chiropractic professionals, attitudes and perceptions was used. An example of search string is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Databases searched included PubMed, CINAHL, AMED, Index of Chiropractic Literature (ICL), and MEDLINE. Initial searches were conducted in January 2021, updated in January 2022, February 2023, and June 2024. There were no date restrictions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExample Search Terms\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[MH \"Physicians, Family\"] OR [MH \"Physical Therapists\"] OR [MH \"Occupational Therapists\"] OR [MH \"Nursing Assistants\"] OR [MH \"Physical Therapist Assistants\"]\u0026nbsp;OR [MH \"Nurses+\"]\u0026nbsp;OR \u0026ldquo;general practitioner*\"\u0026nbsp;OR \u0026ldquo;nurse\u0026rsquo; OR \u0026ldquo;occupational therapist\u0026rdquo; OR \u0026ldquo;Physiotherapist\u0026rdquo; OR \u0026ldquo;Physical Therapist\u0026rdquo; OR \u0026ldquo;surgeon\u0026rdquo; OR [MH \"Surgeons\"]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[MH \"Chiropractors\"] OR [MH \"Chiropractic Practice\"] OR [MH \"Chiropractic\"] OR [MH \"Manipulation, Chiropractic\"] OR \u0026ldquo;Chiropract*\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#1\u0026nbsp;AND\u0026nbsp;#2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[MH \"Attitude of Health Personnel+\"] OR \u0026ldquo;attitude\u0026rdquo; OR \u0026ldquo;perception\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#3 AND #4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eArticle Selection\u003c/h3\u003e\n\u003cp\u003eArticles that met the following criteria were eligible for inclusion in the review: 1. focused on specific exploration of attitudes/perceptions/beliefs of any health professionals (including students) concerning chiropractic/chiropractors or chiropractors using spinal manipulative therapy, 2. primary empirical studies: qualitative, quantitative, and mixed methods, 3. published in English. Papers were excluded if they were: 1. general CAM surveys which did not specifically mention attitudes/beliefs or views concerning chiropractic, 3. if they only explored referral rates without exploring attitudes/beliefs or views of other health care professionals, 3. case studies, non-empirical studies, secondary research, and studies where only the abstract could be sourced were excluded.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTitles and abstracts were screened independently by two authors (KY and JF) using pre-determined inclusion and exclusion criteria. Any variation was agreed upon between these authors and disagreements were resolved, if necessary, with the assistance of a third author (DN). Full texts were read by two reviewers (AN and DN) and data extracted independently. The screening and selection of studies is documented in the PRISMA in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eData extraction and Analysis\u003c/h3\u003e\n\u003cp\u003eData extraction included Title, Author, Date, Design/Method, Jurisdiction, Population, Analysis and Results. Quality assessment was conducted by two reviewers (AN and DN) using the Centre for Evidence Based Medicine (CEBM) qualitative and cross-sectional survey quality assessment tools [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For the quality assessment we categorised the total scores into approximate thirds to provide 3 quality categories (Low, Medium, High). Data extraction and synthesis was also conducted by these two reviewers using a narrative synthesis to collate and integrate the findings of the included studies. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Characteristics and overview\u003c/h2\u003e\n \u003cp\u003eForty-three studies were identified as eligible to be included in the review. (see Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Included studies are categorised by country in and Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Due to delays caused by the COVID-19 pandemic and subsequent delays in registration of the protocol we performed follow up searches in 2022 and 2023 finding one additional eligible study [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. A final search conducted in 2024 failed to identify any further eligible studies.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics and results of included studies.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCitation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDesign/Method\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eAUSTRALIA\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreston-Thomas et al., (1993)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Written questionnaire ,12 multiple choice questions, questionnaire was mailed\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: 100 GPs in the Auckland area\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Piloted on a small sample of 5 GPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 49 GPs responded (49%)\u003c/p\u003e\n \u003cp\u003eResults:\u003c/p\u003e\n \u003cp\u003e\u0026bull; 97% felt that referral by them should always be necessary before spinal manipulation therapy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 40% had moderate to excellent knowledge of chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Knowledge source: 65% from patients, 45% personal communication with therapist, 15% from the media\u003c/p\u003e\n \u003cp\u003e\u0026bull; 9% of GPs have experienced manipulative therapy themselves.\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs who rated themselves as having the greatest knowledge of chiropractic were significantly more likely to refer patients with chronic pain to chiropractic (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than GPs with less knowledge of chiropractic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHopper and Cohen (1998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: 1097 1st, 3rd, and 5th year medical students\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Not documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical Students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 800 students responded (73%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Generally positive towards complementary therapies\u003c/p\u003e\n \u003cp\u003e\u0026bull; Students reported little knowledge of chiropractic despite it being at the time, one of two most common complementary therapies in Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSimpson (1998)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Pseudo random (every second on official list of 3018 I.e., sample 1509)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Not documented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 784 GPs responded (52%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 82% Male\u003c/p\u003e\n \u003cp\u003e\u0026bull; Percentage replying affirmative to following questions comparing Physiotherapists and Chiropractors\u003c/p\u003e\n \u003cp\u003e▪ Legitimate care providers: Chiro 23%/ Physio 95%\u003c/p\u003e\n \u003cp\u003e▪ Treat in hospitals: Chiro 14%/ Physio 95%\u003c/p\u003e\n \u003cp\u003e▪ Remain primary care: Chiro 29%/Physio 63%\u003c/p\u003e\n \u003cp\u003e▪ Ethical to deal with: Chiro 35%/ Physio 99%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePirotta et al., (2000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Survey was mailed to 800 (764 after removal of 36) GPs: non-responders were sent a reminder postcard and follow-up survey if necessary\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Survey was developed from existing literature and using a focus group of GPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 488 GPs responded (64%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 82% Male\u003c/p\u003e\n \u003cp\u003e\u0026bull; 80% reported they knew something about chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 7% thought chiropractic care was frequently harmful, 75% occasionally harmful, 17% not often harmful.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 11% thought chiropractic is Highly effective, 70% occasionally effective, 14% not often effective.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 55% of GPs would practice chiropractic with appropriate training, and amongst these, 69% said that chiropractic should be eligible for Medicare rebates (national health insurance scheme)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 29% of respondents have had patients ask them for a referral, 69% have never referred, 78% have rarely or referred a few times a year and 22% either monthly or weekly refer patients to chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 24% of GPs are interested in training for chiropractic and 8% already had trained.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWardle et al., (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Survey was mailed 1486 GPs and a reminder card was sent after two months.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Survey based on a previous questionnaire and was piloted at the department of general practice in the University of Newcastle.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 698 GPs responded (40.7%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eDescriptive analysis\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Modal age 45 to 55, 53.5% were male.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 23.1% of GPs referred to a chiropractor or osteopath at least once per month, 41.0% at least few times per year, 21.7% stated they would not refer to a chiropractor or osteopath.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Only 2.2% were unable to identify practitioners to refer to\u003c/p\u003e\n \u003cp\u003e\u0026bull; 10.4% of respondents performed manipulative therapies themselves (chiropractic or osteopathic techniques), 21.2% had a personal professional relationship with a specific individual chiro or osteopath.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Significantly more likely to refer if they had a high patient load or had knowledge of chiropractic or osteopathy.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eInferential analysis\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs who believed in the efficacy of chiropractic or osteopathy, had seen positive results or who perceived access to medical specialists not being a driver for CAM use were significantly more likely to refer.\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs who had not seen positive result were 2.41(95% CI: 1.18, 5.12) time more likely to refer if there was no other option available.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEngel et al., (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Survey was mailed 24,377 GPs currently working in Australian private practice\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Tested on a focus group of 19 experienced vocational trainers at GP conference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 630 GPs responded (2.6%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Greatest proportion of respondents were \u0026gt;\u0026thinsp;40 and had\u0026thinsp;\u0026lt;\u0026thinsp;10 years in practice compared to the national average.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 30% obtained information about chiropractors from medical journals.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 66% disagreed that there was a growing body of evidence on the efficacy of chiropractic\u003c/p\u003e\n \u003cp\u003e70% believed chiropractic education was not primarily evidence based.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 62% responded in a negative way to \u0026quot;would a better understanding of chiropractic make you reconsider referring a patient to a chiropractor?\u0026quot;\u003c/p\u003e\n \u003cp\u003e32% agreed they would co-manage a patient with a chiropractor if clinically appropriate.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 29% strongly agreed or agreed that the ability to understand the role of a chiropractor have been affected by media coverage.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 31% were either dissatisfied or very dissatisfied with the communication between themselves and chiropractors, 41% hadn\u0026rsquo;t had enough communication to respond to the question.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 49% reported having patient referred to them by a chiropractor.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 68% reported not being interested in learning more about the education of chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Top three conditions that GPs thought chiropractors could be helpful were: mechanical LBP, neck, and upper BP, cervicogenic headaches.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrace et al., (2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Qualitative: Critical Realist analysis of free text responses of prior survey (Engel)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: NA\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Original survey targeted the 24,377 GPs currently working in Australian private practice\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: NA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 184 GPs responded with free text (0.7%) (original survey, Engel)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThemes\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e1. \u003cem\u003eChiropractic Is Not a Safe Practice\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e2. \u003cem\u003eThere Is a Lack of Evidence to Support Chiropractic and Osteopathy\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e3. \u003cem\u003eChiropractors and Osteopaths are insufficiently trained and should not be allowed to practise as primary contact health practitioners.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e4. \u003cem\u003eChiropractors make financially motivated decisions about treatment that are associated with false advertising.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e5. \u003cem\u003eChiropractic and osteopathy are redundant due to the presence of physiotherapy.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Unfavourable responses towards chiropractic were far greater than osteopathy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 13% raised concerns about the potentially harmful side effects associated with chiropractic but not osteopathy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 21.7% referred to the lack of evidence for the efficacy of chiropractic intervention. A similar proportion also raised the same concerns regarding osteopathy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 12% reported chiropractic and osteopathy offered real benefits particularly for MSK issues but cited the mechanism as due to patient belief.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 24.5% raised issues of credibility with the education background of chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 10.3% referred to unwillingness to refer patients to chiropractors due to an inability to identify \u0026quot;good\u0026quot; and \u0026quot;bad\u0026quot; chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 73% identified the antivaccination stance of some chiropractors as problematic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 32.1% concerned about chiropractors making financially motivated decisions and their use of false claims about the benefits of chiropractic intervention in advertising.\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs expressed the opinion that they can refer patients to physiotherapists for treatment of MSK conditions making chiropractic and osteopathy redundant.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCANADA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNewton-Leo et al., (1994)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: All (148) GPs listed in Canadian Medical Association in Downsview were contacted. Of these 70 were sent the survey based on expectation they would response based on secretary\u0026rsquo;s advice.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Revision of a questionnaire used by LeBrun et al (1978) including rewording\u003c/p\u003e\n \u003cp\u003esome questions and deleting others. Survey underwent face validity with professionals and lay public.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 26 GPs responded (37%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 69% unaware of length of training\u003c/p\u003e\n \u003cp\u003eSome thought reflexology, homeopathy and iridology were part of the curriculum (54,31 and 19% respectively)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 92% thought chiropractors diagnosed MSK, but only 65% felt they could control pain\u003c/p\u003e\n \u003cp\u003e\u0026bull; Only 31% were aware that risk of cardiovascular event due to cervical spine adjustment was very low.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 88% had refereed and 65% had had referral\u003c/p\u003e\n \u003cp\u003e23% had been treated\u003c/p\u003e\n \u003cp\u003eOpinions: 91% positive to neutral; agreed working with chiropractors collaboratively would improve patient\u0026rsquo;s health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVerhoef and Sutherland (1995)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Mailed to 400 GPs (200 Ontario, 200 Alberta). Subsample of non-respondents were mailed a brief one-page questionnaire addressing age, sex and perceived usefulness of complementary medicine.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Survey was adapted from a previous questionnaire and rated the practitioner\u0026rsquo;s level of knowledge of chiropractic, usefulness, and effectiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: Alberta 124 (62%), Ontario 86 (43%), non-respondent survey (43%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Majority male 69%, urban practice (69%), mean age 44 SD\u0026thinsp;=\u0026thinsp;9.5\u003c/p\u003e\n \u003cp\u003e\u0026bull; 65% said there is a perceived demand for complementary therapy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 44% of the total sample stated they referred patients to chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Ontario physicians were more likely to refer patients (60% and 32% respectively)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Referrals were predominantly back pain, MSK pain, chronic pain. Reason for referral were non-response to conventional medicine and patient preference.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Only 1 participant had received training on chiropractic and 6% wished to receive training1/5th of the participants indicated that chiropractic influenced their opinion on complementary therapy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Level of \u0026quot;some\u0026quot; knowledge (majority of respondents): Ontario (65%) Alberta (68%)\u003c/p\u003e\n \u003cp\u003e\u0026bull; General usefulness: Majority \u0026quot;Useful,\u0026quot; Ontario: 43% Alberta: 52%\u003c/p\u003e\n \u003cp\u003e\u0026bull; Effectiveness for neck/back pain problems: Majority \u0026quot;Somewhat\u0026quot; Ontario: 35%, Alberta: 44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVerhoef and Page (1996)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComments extracted via secondary analysis of above survey (Verhoef et al, 1995)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Approximately 1/5th of the comments offered by participants mentioned chiropractic specifically.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003ePositive Views\u003c/em\u003e: Most of these comments suggested that the positive view of chiropractic was due to feedback/results heard/observed in patients or family members who had received chiropractic care or because of chiropractic services they had received or from professional interactions they had with them. Only two practitioners reported positive views arising from reading scientific literature.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003eBalanced views\u003c/em\u003e: Around a \u0026frac14; of respondents provided both positive and negative experiences regarding chiropractic. Management of MSK conditions was deemed appropriate but was not considered so for non MSK (e.g., asthma, diabetes. These views arose from anecdotal reports from patients.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003eNegative views\u003c/em\u003e: Only 5 respondents provided negative responses with some suggesting that chiropractors focused on financial gain.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGarner et al., (2008)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: A mixed method\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaires and Focus Groups\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Two community health centres (CHCs) in Ottawa, Ontario. Assessment was recorded at baseline 9 months and 18 months after chiropractor joined. Educational sessions were run to post first 2 focus groups to expose providers to evidence-based chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Questionnaire used a seven-point Likert scale and was pilot tested including face validity at both CHCs before the study began\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysicians\u003c/p\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePopulation: Twelve providers were assessed\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mean age was 44.1 years of age, range of experience 2-5years, each practitioner had worked for 5\u0026thinsp;+\u0026thinsp;years.\u003c/p\u003e\n \u003cp\u003e\u0026bull; There was a statistically significant (P\u0026thinsp;=\u0026thinsp;0.004) increase willingness to trust chiropractic in shared care cases and greater respect for the chiropractor\u0026rsquo;s knowledge and skills (p\u0026thinsp;=\u0026thinsp;0.008) post educational intervention.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Further changes were also noted post inclusion of the chiropractor including, legitimacy and effectiveness of chiropractic moved from neutral to more positive, providers indicated that chiropractic care was safer than anti-inflammatory medication, scepticism about efficacy and safety was \u0026quot;dissipated\u0026quot; and questions regarding experience with chiropractic and patient outcomes moved from neutral to positive\u003c/p\u003e\n \u003cp\u003eAnalysis of focus group data saw a shift within medical teams from a negative and limited view of chiropractic to generally more positive attitude. E.g., thick quotes included,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I have only had positive feedback from many of the clients; they have always had some sort of change in their outcome, and they have always had some sort of positive thing to say.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eWe are able to give patients hope and encouragement, and actually, I have a lot of patients that it (chiropractic) helped with their pain reduction and certainly has taken the burden off me psychologically and time wise\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusse et al., (2009)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Random sample n\u0026thinsp;=\u0026thinsp;500 for both Canada and US. Power calculation for multivariable regression suggested 240 completed returns were needed. Canadian (total population 764) and US (total population 24,172\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Chiropractic Attitudes Questionnaire CAQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrthopaedic Surgeons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 680 completed surveys from 1000 sent (68%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 71% not exposed to information on chiros during medical school (of the 139 that were only 7% reported favourable exposure)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 86% respondents said attitudes were formed after medical school\u003c/p\u003e\n \u003cp\u003e(29% positive views/45% negative views)\u003c/p\u003e\n \u003cp\u003e\u0026bull; US more likely to agree that neck manipulation is safe and there are ideas that could benefit wider healthcare/ Canadian more likely to agree chiro had adequate training, did not engage in aggressive marketing, and did not breed dependency.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Variables that were associated with attitudes were, relationship with specific chiropractor, Research literature, medical school, and age\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusse et al., (2011)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Thematic analysis of written comments in above survey (Busse et al, 2009)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrthopaedic Surgeons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 680 completed surveys from 1000 sent (68%) and 174 provided written comments (25% of original 680 respondents)\u003c/p\u003e\n \u003cp\u003eResults: Themes identified\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eVariability amongst chiropractors\u003c/strong\u003e \u003cem\u003e\u0026ldquo;Wide range of practice - some are evidence based...others do all sorts of crazy stuff\u0026ldquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eChiropractic care perceived as effective\u003c/strong\u003e \u003cem\u003e\u0026ldquo;I find their usefulness is limited to lumbar mechanical back pain care\u0026ldquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eChiropractic care perceived as unhelpful/problematic\u003c/strong\u003e \u003cem\u003e\u0026ldquo;Chiropractors are dangerous when they portray themselves as replacements for patients\u0026rsquo; primary care physicians\u0026ldquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eChiropractic rationale\u003c/strong\u003e \u003cem\u003e\u0026ldquo;The concept of \u0026lsquo;adjusting subluxations\u0026rsquo; is nonsensical\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eChiropractic training\u003c/strong\u003e \u003cem\u003e\u0026ldquo;Life chiropractors are scary\u0026ldquo;, and \u0026ldquo;I visited the Canadian Memorial Chiropractic College in Toronto. I was impressed with the similarity of their basic science curriculum - same books as used in medicine - and the extent of information covering all symptoms. This does not seem to be the case for all schools in North America\u0026ldquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eUnethical behaviour\u003c/strong\u003e \u003cem\u003e\u0026ldquo;Major problem as I see it, chiropractors tend to place patients on an \u0026lsquo;x amount of treatment\u0026rsquo; plan such as 20 visits. In my opinion they need to perform the service and see if the patient responds and proceed from there. Not just say \u0026lsquo;you need an x amount of treatment\u0026rsquo; plan\u0026ldquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eScientific basis\u003c/strong\u003e \u003cem\u003e\u0026ldquo;Most students now have undergraduate degrees and are relatively well educated in basic sciences in their first 2 years (preclinical). The problem begins when they move into their clinical years where education becomes \u0026lsquo;indoctrination\u0026rsquo;. \u0026ldquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003ePersonal experience\u003c/strong\u003e \u003cem\u003e\u0026ldquo;I need more knowledge to utilize chiropractors better!\u0026ldquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChung et al., (2012)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Questionnaire intervention: Implicit association test (IAT) developed to test attitudes toward chiropractic and medical care\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling : A convenience sample was recruited from students\u003c/p\u003e\n \u003cp\u003eand faculty associated with a Physical Therapy program.\u003c/p\u003e\n \u003cp\u003e\u0026bull; A survey determined which words best reflected the profession of either chiropractic or medicine. These words were used in the word association task of the IAT.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Explicit questions followed by a list of words were developed.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical therapy students and faculty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParticipants: Total of 49 participants, majority female and mean age of 29, majority in 1/2nd year, only 29% previous experience\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most had a preference of medical treatment (91% preferred and 81% agreed with medicine)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Explicit prejudice was an average of 53% which might be considered neutral rather than prejudiced or accepting.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Implicit attitudes suggest strong negative implicit bias toward chiropractic (That is, the word association task took statistically significantly longer to complete when \u0026ldquo;chiropractic\u0026rdquo; was paired together with \u0026ldquo;positive\u0026rdquo; terms than when \u0026ldquo;chiropractic\u0026rdquo; was paired together with \u0026ldquo;negative\u0026rdquo; terms)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWong et al., (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Mixed methods approach (survey, interviews and focus group)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire, 20 min interviews and single focus group (1hr).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Survey, all of Year 2 n\u0026thinsp;=\u0026thinsp;224); Focus Group n\u0026thinsp;=\u0026thinsp;8; Interviews n\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: developed through a literature review to discern thematic areas suggested by current studies. Face validity using 4 students.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical Students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 112 completed surveys (50%), equal female/male ratio\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eQuantitive\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; Responses to questions positive, negative, undecided\u003c/p\u003e\n \u003cp\u003e\u0026bull; Largest proportion had poor knowledge of chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Individuals with poor knowledge significantly indicated don\u0026rsquo;t know/undecided to questions.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Individuals with previous experience indicated more positive (if friend or family member then considered it as a career, received chiropractic care and more positive)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Individuals who responded no to learning more about chiropractic were significantly more negative attitudinally.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Highest proportion undecided as to chiropractic being a mainstream profession but agreed it was CAM.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Highest proportions were undecided that the medical school was knowledgeable about chiropractic but agreed that\u003c/p\u003e\n \u003cp\u003eInterprofessional education was important.\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eQualitative Themes\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eKnowledge of chiropractic\u003c/strong\u003e \u003cem\u003e\u0026ldquo;I do remember hearing some injuries that can be caused when people have some specific condition, but I don\u0026rsquo;t think we\u0026rsquo;ve ever had anything really too positively that I can recall in lecture.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eChiropractic in medical education\u003c/strong\u003e \u003cem\u003e\u0026ldquo;We did have an interprofessional development day\u0026hellip; and there weren\u0026rsquo;t any alternative medicine or chiropractors, and I feel that would be a good opportunity to introduce students to it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eRole of chiropractic in healthcare\u003c/strong\u003e \u003cem\u003e\u0026ldquo;If I were the practicing physician, I may not choose (chiropractic) treatment for a patient just because I don\u0026rsquo;t understand it. If I understood the risks and benefits to particular patients, I would definitely have a positive attitude towards it and know when to access it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cstrong\u003eChiropractic in clinical settings\u003c/strong\u003e \u003cem\u003e\u0026ldquo;If (chiropractors) are part of the same healthcare team then it would be easier for the patient to access all the services in the same place and part of the same group of circle of care.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWong et al., (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Mixed methods (survey and focus group)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Follow up using survey used in study above (Wong et al 2013) post a 1 hr intervention\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sample: As above\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: As above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical Students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate :Of 112 students (50% of class) 58 responded (26% of class) post 1hr intervention.\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Attitudes differed between pre and post intervention.\u003c/p\u003e\n \u003cp\u003e\u0026bull; A statistically significant increase in number of attitude-positive\u003c/p\u003e\n \u003cp\u003eresponses (p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), decrease in attitude-negative (p .03) and decrease in undecided responses (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003cp\u003e\u0026bull; In terms of understanding of chiropractic, post intervention, participants ranked themselves significantly higher as a group (p\u0026thinsp;\u0026lt;\u0026thinsp;.0002) and a larger percentage rated themselves as having at least a \u0026lsquo;\u0026lsquo;Good\u0026rsquo;\u0026rsquo; understanding of chiropractic (35.1% vs 21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeis et al., (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Online questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sample: 659 or 1433 members of the Society of Obstetricians and Gynaecologists of Canada\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Modified existing survey was designed to assess attitudes of obstetricians towards chiropractic care for pregnant patients with LBP. Added Chiropractic Attitude Questionnaire (CAQ). Piloted with a group of 5 staff obstetricians.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObstetricians\u003c/p\u003e\n \u003cp\u003eGynaecologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate : 91 completed surveys ((14%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 63.7% Female, 78.1% practiced for \u0026gt;\u0026thinsp;5 years, 54.9% practiced in hospitals, 84% endorsed general obstetrics as their area of specialism.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Positive, neutral, or negative views equally distributed in the sample.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 40% referred at least some patients for chiropractic care each year; patient request (31.9%) nonresponse to medical treatment (20.9%).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Views of chiropractic primarily from patient feedback (48.4%), family and friends (39.6%), personal treatment experience (26.4%), or a relationship with a specific chiropractor (20.9%).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most respondents (56%) were interested in learning more about chiropractic care.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mean CAQ score was 41.2 (max positive score obtainable was 80)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most participants strongly agreed or agreed that chiropractors provide effective therapy for some musculoskeletal conditions (76.6%), that chiropractors provide a patient- centred approach (57.7%), and that chiropractic care is a useful supplement to conventional medicine (60.0%).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most respondents disagreed (32.2%) or strongly disagreed (42.2%) that chiropractors can provide effective therapy for non- musculoskeletal conditions, and 54.4% of respondents disagreed or strongly disagreed that chiropractic manipulation of the neck is a safe therapy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 39% viewed chiropractic care as effective for pregnant patients with LBP.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Trend suggested personal experience with chiropractic resulted in higher scores.\u003c/p\u003e\n \u003cp\u003e\u0026bull; No variables significantly predicted positive attitudes although personal treatment experience was near statistical significanc\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusse (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Follow up survey (Busse et al 2009) of a random sample of Canadian family physicians (directory of possible 2429 participants).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Chiropractic Attitudes Questionnaire CAQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily Physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 162 respondents (7%) Approximately half of respondents\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Majority endorsed a positive impression of chiropractic care, but a quarter held negative views.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most respondents referred at least some patients for chiropractic care.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most physicians believed that chiropractors provide effective therapy for some musculoskeletal complaints and most disagreed that chiropractic care was beneficial for non-musculoskeletal conditions.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The majority agreed that chiropractic care was a useful supplement to conventional care, but most respondents also indicated that practice diversity among chiropractors presented a barrier to interprofessional collaboration.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Attitudes towards chiropractic care changed trivially over the decade from the original survey in 2010 to present survey in 2019 with only 1/3rd of a point improvement on an 80-point scale.\u003c/p\u003e\n \u003cp\u003e\u0026bull; More negative attitudes were associated with older age, belief that adverse events are common with chiropractic care, reported use of the research literature or medical school as sources of knowledge.\u003c/p\u003e\n \u003cp\u003e\u0026bull; More positive attitudes were associated with endorsing a relationship with a specific chiropractor.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZivcic (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling:. Snowball method (chain of referrals that starts with the identification and locating of a certain number of target population members that satisfy the pre-established criteria)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: MAQ (Integrative Medicine Attitude Questionnaire). Modifications made in translation to Croatian. Larger the score more favourable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysiotherapists\u003c/p\u003e\n \u003cp\u003ePhysicians\u003c/p\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003cp\u003eParamedics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;325 replied, 104 Physiotherapists, 98 Physicians, 123 Nurse/Paramedics. (response rate not reported)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Single question referring to chiropractic care: \u003cem\u003eChiropractic is a valuable method of resolving a wide variety of musculoskeletal problems (not just back pain);\u003c/em\u003e Maximum score is 7 where 1 is absolutely disagree and 7 is absolutely agree.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physicians mean score, 3.41.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physiotherapists mean score, 3.33.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Nurses/paramedics mean score 3.59.\u003c/p\u003e\n \u003cp\u003e\u0026bull; No statistical difference between groups.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNETHERLANDS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLangworthy et al., (2000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Random sample of 299 Physiotherapists (Ps) from a list of 500 provided by national association. Also sent to 100 Manual Therapists (MTs) and 95 Osteopaths (Os) (Total 494)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Survey constructed for the study around opinions about chiropractic. Piloted for face validity.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysiotherapists (Ps)\u003c/p\u003e\n \u003cp\u003eOsteopaths (Os) Manual Therapists (MTs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReponses rate: 237 responses returned (48%)) (Proportions, 50% MTs, 45% Ps, 52% Os)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most Os and MTs were male whilst most Ps were female.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 70% Os thought it their knowledge was good but only 1% of MTs and 7% of Ps said they had \u003cem\u003eonly heard something.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; 1/3rd encountered chiropractic care through their patients.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 10% of Ps and 25\u0026ndash;33% of MTs and Os had heard of chiropractic during training.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Around 1/5th of Os and Ps heard through media although this was least preferred with most preferring information via published research.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Around 1/2 MTs and 2/3rd Ps and Os had had no contact with chiropractors\u003c/p\u003e\n \u003cp\u003e\u0026bull; Existing levels of communication and cooperation between the professions was considered poor to non-existent by over 80% of respondents; felt it should be improved and would help professionals and patients.\u003c/p\u003e\n \u003cp\u003e\u0026bull; All Os and 1/2 MTs and Ps thought chiropractors were skilled practitioners especially if they had personal experience but around 2/3 of MTs and Ps saw chiropractors as competition.\u003c/p\u003e\n \u003cp\u003e\u0026bull; MTs and Ps were generally unsupportive of statutory registration of chiropractors in The Netherlands.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBrusse et al., (2001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: 252 questionnaires were sent to GPs in 84 cities where chiropractors were working with addresses obtained from The Netherlands Institute for Research in Primary Care, which randomly chose 3 addresses in each city\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Piloted by stakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 115 returned questionnaire (46%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Knowledge about chiropractic was high although the depth of knowledge varied extensively.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 78% of knowledge came from patients being treated by chiropractors the rest from colleagues or medical journals (26%, 25%)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 10% of GPs regularly referred. For those that did it was significantly related to knowledge of or positive relations with chiropractors\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026gt;\u0026thinsp;80% wanted more information about and more feedback from chiropractors even if they didn\u0026rsquo;t refer.\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs felt Chiropractic reports often contained confusing terminology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNEW ZEALAND\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoynton et al., (2006)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Nationwide random sample of 500 GPs from a population of 2358 were mailed a two-page questionnaire. A second questionnaire was sent to non-responders 2.5 weeks later.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Informed by previous research\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 300 of the 499 eligible practitioners replied (60%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mean age was 50.3.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 42.7% saw chiropractic manipulation as conventional medicine.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 79.7% of respondents rated chiropractic as moderately, very, or highly beneficial.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 77.7% have referred to a chiropractor.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNORWAY/SWEDEN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWestin et al., (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Sent to every other GP in proportionate numbers to the numbers of GPs in Sweden and Norway. N\u0026thinsp;=\u0026thinsp;1600 surveys sent\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Informed by 2 Master-projects from the Anglo-European College\u003c/p\u003e\n \u003cp\u003eof Chiropractic in England.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse Rate: 735 total returned (Sweden, 44.8%; Norway, 45.3)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Around half of GPs were older than 50 with around 60% being male in both countries\u003c/p\u003e\n \u003cp\u003e\u0026bull; In Sweden over 50% said they had poor knowledge and in Norway 12%\u003c/p\u003e\n \u003cp\u003e\u0026bull; Regarding education as being satisfactory, 49% and 80% agreed in Sweden and Norway respectively.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Regarding competency to treat MSK, 69% and 93% agreed in Sweden and Norway respectively.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Unusual terminology was perceived by 11 and 23% in Sweden and Norway respectively.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Regarding patient experience, 47% and 66% agreed this was good in Sweden and Norway respectively.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Only 12% and 3% agreed a variable or bad patient experience in Sweden and Norway respectively.\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs stated they had been asked about recommendation (43% and 79% Sweden and Norway respectively) (NB: GPs in Sweden cannot refer)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSOUTH AFRICA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLouw and Myburgh (2007)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Random sample of 596 practitioners were drawn from medical practitioners in South Africa, working as GPs in one of five selected cities. Total population of 4448 GPs in private practice (South African Medical Association database),\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Questionnaire developed by Langworthy et al, 2000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: Participants returned 596 questionnaires (13.8%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 80% knew something about chiropractic, 20% nothing\u003c/p\u003e\n \u003cp\u003e43% communicated, 9% regularly: just over half respondents reported positive experience.\u003c/p\u003e\n \u003cp\u003e\u0026bull; There was a highly statistical associated with how much knowledge GPs reported and referral/communication.\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs strongly identify chiropractors with the management of neuro-musculoskeletal disorders.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 44% were in favour of regular chiropractic visits to prevent the onset of\u003c/p\u003e\n \u003cp\u003erecurrent conditions.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Role of the chiropractor is perceived as one of referral and rehabilitation, rather than primary contact.\u003c/p\u003e\n \u003cp\u003eExample quotes\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003eChiropractic provides a useful, non-invasive modality for numerous medical conditions,\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eespecially back and other musculoskeletal pain.; Chiropractors are very under-utilized; they could do much more, doctors need to know more about what they do.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003eI don\u0026rsquo;t feel chiropractors add greatly to the health of general population especially the poor.; I am not sufficiently informed about chiropractors and their ability, to refer patients to them. I feel that physiotherapists are best able to deal with these problems and I get good results with them.: Chiropractors tend to overtreat.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNaidoo and B\u0026uuml;hler (2009)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Questionnaires given to first and final-year physiotherapy (n\u0026thinsp;=\u0026thinsp;72) and chiropractic students (n\u0026thinsp;=\u0026thinsp;49) (n\u0026thinsp;=\u0026thinsp;127 in Durban, KwaZulu-Natal.)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: The questionnaire was piloted for content validity using second year physiotherapy students. No changes were made post the pilot study.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 38 1st year and 34 final year physiotherapy students responded (100% return rate)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 92%, 85% female and mean age was 19 and 22 in year 1 and 4 respectively.\u003c/p\u003e\n \u003cp\u003ePercentage knowledge of chiropractic average score for 1st and final year students was 58 and 62% respectively.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Proportion of class who saw the chiropractors as direct competition was 84% and 76% in 1st year and 4th year respectively (The main reason cited for this is that \u0026ldquo;Physiotherapists and chiropractors do things that are similar\u0026rdquo; or \u0026ldquo;Chiropractors do everything originally done by physiotherapists\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Four percent of the first-year students felt \u0026ldquo;rehabilitation is not done by chiropractors.\u0026rdquo; Final year physiotherapy students felt that the skills physiotherapists have are \u0026ldquo;more and different\u0026rdquo; with \u0026ldquo;treatment of the chest and musculoskeletal system.\u0026ldquo;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Six percent felt that \u0026ldquo;Chiropractors are doctors but do things that are actually physiotherapy techniques.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Forty five percent first year and 53% final year physiotherapy students reported that they would like to work more closely with chiropractors.\u003c/p\u003e\n \u003cp\u003ePhysiotherapy students listed some of the following as barriers or facilitators for improved working relations with chiropractors as follows:\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026ldquo;Chiropractors take over the Physiotherapists job\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026ldquo;Unfair that Chiropractors are called doctors; what about physio- therapists?\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026rdquo;Both professions are equally important, but their domains should be separated\u0026rdquo;, \u0026ldquo;Would like to know more about chiropractors\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026ldquo;Physiotherapy needs to be marketed more\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026ldquo;There is place for both professions, therefore there is no need for competition\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026ldquo;Both professions need more knowledge and information about each other.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThondhlana et al., (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Total population of 88 registered private GPs in Harare as of October 2017. Sample size calculation (95% confidence interval) suggested 72 doctors as appropriate to provide generalisability to the entire population of GPs in Harare\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: A self-administered questionnaire, adapted from those used in similar studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 48 respondents (55%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Approximately one-third had never heard of chiropractic care.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Of the two thirds that had, almost 66% believed chiropractors to be competent in the treatment of musculoskeletal complaints and approximately one-third in the treatment of neurological ailments.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 40% of GPs believed that chiropractors were adequately trained to play a role in mainstream medicine, but the majority were unsure whether chiropractors\u0026rsquo; education was adequate in this regard.\u003c/p\u003e\n \u003cp\u003e\u0026bull; More than half of the respondents agreed with chiropractic referral for musculoskeletal conditions.\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs perceptions rather than knowledge appeared to determine the utilisation (referral) of chiropractors by GPs.\u003c/p\u003e\n \u003cp\u003eMain reason for non-referral of musculoskeletal complaints to a chiropractor was lack of knowledge by the GP followed by uncertainty of treatment efficacy and the belief that there were no chiropractors in the area\u003c/p\u003e\n \u003cp\u003e\u0026bull; GPs who were more knowledgeable also had more positive perception of the profession.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUK\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerkin et al., (1994)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Questionnaires sent to 100 randomly selected GPs and hospital consultants and 237 preclinical medical students from two UK schools. A second questionnaire was sent to non-responders.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Not reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs (GPs)\u003c/p\u003e\n \u003cp\u003eHospital Doctors (HDs(\u003c/p\u003e\n \u003cp\u003eMedical students (MS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 87 GPs, 81 HDs and 230 MS completed questionnaires (87% GPs, 81% HD and 97% MS)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 51% of MS, 91% of HDs and 82% of GPs had heard of chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 15% of MS, 49% of HD, and 60% of GPs knew the principles of chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 5% of MS, 8% of HD, and 33% of GPS knew the qualifications needed to be a chiropractor.\u003c/p\u003e\n \u003cp\u003e\u0026bull; In all three of these items GPs were statistically significantly more knowledgeable\u003c/p\u003e\n \u003cp\u003e\u0026bull; In terms of referral to chiropractic 14% of HDs referrals were suggested by the doctor and 7% was suggested by the patient. In contrast, 54% of GPs referrals were suggested by the doctor and 51% were suggested by the patient a statistically significant difference between professionals.\u003c/p\u003e\n \u003cp\u003e\u0026bull; In comparison to the other alternative therapies, significantly less medical students had heard of chiropractic.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite et al., (1997)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: All GPs on register in Devon and Cornwall (n\u0026thinsp;=\u0026thinsp;972).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Piloted questionnaire created by authors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 461 returned questionnaire (47%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 77% Male\u003c/p\u003e\n \u003cp\u003e\u0026bull; 46%% either referred to or endorsed chiropractic (highest of the CAM therapies mentioned in this study), with the most common profession referred to in the previous week being osteopathy or chiropractic (18% referred 63% recommended)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 69% rated osteopathy and chiropractic as effective (highest rating) and 56% thought chiropractic care should be included in the NHS (slightly higher than Osteopathy (52%))\u003c/p\u003e\n \u003cp\u003e\u0026bull; Adverse events were mentioned by 38% most being around spinal manipulation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerry and Dowrick (2000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Questionnaires sent to all GP principals registered with Liverpool Health Authority (n\u0026thinsp;=\u0026thinsp;252). One reminder was sent to non-responders 3 weeks later.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Piloted with 20 GPs, five clinical members were also used to ensure reasonable response rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 131 questionnaires were returned (52%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Younger doctors were significantly more likely to respond than their older colleagues.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 7% or GPs refereed and 11% endorsed chiropractic care.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 1 GP used manipulation with their patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchmidt et al., (2002)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: In the UK, the local health authority provided a list of addresses for GPs by electoral ward in the Plymouth area. This list did not constitute a random sample but was ordered according to geographical area (n\u0026thinsp;=\u0026thinsp;97). German GPs were selected by randomly choosing addresses from the Yellow Pages for Mecklenburg Vorpommern, a north-eastern region in Germany (formerly German Democratic Republic) (n\u0026thinsp;=\u0026thinsp;99)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Questionnaires developed based on previous literature and piloted GPs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate UK 133 (69%), Germany 67 (68%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Majority were male (94% UK and 63% German). British sample practicing longer.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Overall, more positive in Germany than UK toward CAM in general\u003c/p\u003e\n \u003cp\u003e\u0026bull; The most popular UK GPs referred their patients to were chiropractic treatment (79%), acupuncture (67%) and osteopathy (66%).\u003c/p\u003e\n \u003cp\u003e\u0026bull; German GPs referred their patients mainly to acupuncture treatment (82%), chiropractic treatment (73%) and herbal medicine (28%)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most GPs, irrespective of country, were concerned about the lack of scientific evidence about CAM. British GPs were also highly concerned about lack of knowledge about its indications and the lack of availability on the NHS.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 8% and 11% of UK and German GPs claim to have practiced chiropractic and 6% of UK GPs had used chiro (the highest use) and 7% in Germany (second highest)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDavidson., (2007)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Postal survey GPs in Grampian, Scotland with 433 receiving the questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Questionnaire designed for study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 135 completed the questionnaire (31%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 48% had heard of chiropractic treatment for children and 11.8% knew of a chiropractor in the area who treated children.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 74% would prefer written communication and 78% would communicate by letter to a chiropractor.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 60% would like to know more about the efficacy and scope of practice.\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;1% GPs believed chiropractic paediatric care is evidence based.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 46% of GPs believed chiropractic can treat sports injuries, scoliosis 37%, torticollis 37.9%, growing pains 31.1%, headaches 25.2%, colic 20%\u003c/p\u003e\n \u003cp\u003e\u0026bull; 4.4% had received paediatric referral from chiropractor and 2.2% had referred a child to the chiropractor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKier et al., (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: 385 GPs were contacted representing approximately 20% of the GPs in Wales.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Short questionnaire was designed and initially piloted internally for face/construct validity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 182 participants completed the questionnaire (51%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 64.8% were male and 79% were 40+\u003c/p\u003e\n \u003cp\u003e\u0026bull; 26.4% of GPs had personally sought treatment from and 72% indicated that they had referred a patient to a SMT practitioner.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 21% GPs indicated they have not and would not refer a patient to a SMT practitioner.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 13% of GPs personally would seek of consider seeking chiropractic therapy specifically and 7% would consider referring their patient to chiropractor.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerry et al., (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Sent to all GPs registered with Liverpool Primary Care Trust. Reminders were sent at 3 weeks and further postal drop at 3 months.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Questionnaire was adapted from the one used Perry (2000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: 78 returned the survey (32%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Changes since 2000 survey was a reduction in referral (7\u0026ndash;4%) and endorsement (11\u0026ndash;8%) but an increased confidence in discussing chiropractic (18 to 28%)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Only 8% of those that completed the questionnaire discussed chiropractic with patients.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mean effectiveness of chiropractic was judged as second highest of included CAMs (44%, where 100% represented completely effective)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 40% of respondents reported that their patients had experienced benefit from chiropractic care in the past three months.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most frequent adverse event observed was increased pain from chiropractic manipulation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUSA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReiter (1965)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Format: Face to face interview\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: 33 randomly selected physicians were interviewed.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Questionnaire was adapted from the one used Perry, 2000 (REF). Physicians were asked to use a 5-point Likert scale to answer the questions (1\u0026thinsp;=\u0026thinsp;extremely unfavourable; 5 extremely favourable)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate 33 participants completed the interviews (100%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mean ranking across three professions: Podiatrist 3.2, Osteopaths 2.7, Chiropractors 1.3\u003c/p\u003e\n \u003cp\u003e\u0026bull; Ratings indicated that chiropractors are generally very unfavourably perceived compared to osteopaths and podiatrists.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Total average rating for osteopaths and podiatrists were significantly higher than that for chiropractors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGordon et al., (1998)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Questionnaires were sent out to 1027 Physicians and 225 Obstetricians and Gynaecologists.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Not reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysicians\u003c/p\u003e\n \u003cp\u003eObstetrics\u003c/p\u003e\n \u003cp\u003eGynaecologists\u003c/p\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: Physicians n\u0026thinsp;=\u0026thinsp;624 (61%) Obstetrics, Gynaecologists n\u0026thinsp;=\u0026thinsp;157 (70.4%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 34% of adult primary care clinicians and 38% of Obstetrics/Gynaecologists have used or recommended Chiropractic therapy.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 52.% of adult primary care clinicians and 58% of Obstetrics/Gynaecologists would like the health maintenance organisations (HMOs) to make Chiropractic available to members\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMainous et al., (2000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: A random sample of 400 family physicians was selected from the American Board of Family Practice Membership\u003c/p\u003e\n \u003cp\u003eand Resource Directory\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Not reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily Physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;400 questionnaires completed (39%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Family physicians are much less likely than chiropractors to feel that chiropractors are primary care practitioners.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Although physicians are significantly less likely than chiropractors to feel comfortable sharing care, neither group is particularly oriented toward wanting to share care.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physicians\u0026rsquo; perceptions of \u003cem\u003echiropractors as an excellent source of care for some musculoskeletal problems\u003c/em\u003e was 2.50 but was 4.25 In response to the question that \u003cem\u003echiropractors are an excellent source of care for some nonmusculoskeletal problems\u003c/em\u003e (1\u0026thinsp;=\u0026thinsp;strongly agree; 5\u0026thinsp;=\u0026thinsp;strongly disagree)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChan and Wong (2004)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Questionnaire mailed to all physicians on list provided by Hawaii Medical Service Association (n\u0026thinsp;=\u0026thinsp;1713)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Survey developed based on existing literature of national and regional surveys assessing physician knowledge attitudes and practice of CAM.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;299 physicians responded (17.5%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physicians reported moderate knowledge about chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractic was perceived as therapy but not as having a role in conventional medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGreene et al., (2006)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Survey sent to all physicians and DO\u0026apos;s (Primary Care Physicians) in Iowa (n\u0026thinsp;=\u0026thinsp;1561).\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Initial pilot using a convenience sample of primary care practitioners (PCPs).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary care practitioners (PCPs; Medical doctors (MDs)\u003c/p\u003e\n \u003cp\u003eDoctors of Osteopathy (DOs))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;517 responses (33%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; Most PCPs willing to suggest patients see a chiropractor but unwilling to formally refer with 88% preferring their patients contact chiropractors themselves. Reasons included fear of litigation, that alternative care providers may be a threat to their practice, they did not have enough knowledge or didn\u0026rsquo;t see chiropractic as a legitimate profession.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Odds of accepting referrals were 67% higher in male than female PCPs\u003c/p\u003e\n \u003cp\u003e\u0026bull; Common reasons for referring a patient to a chiropractor were: back/neck pain, unresponsive chronic pain, fibromyalgia\u0026rsquo;s and MSK conditions.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 81% of DOs and 87% of MDs reported that their patients had asked them for information on chiropractic.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 75% of PCPs have patients who have requested a referral to a chiropractor, with 65% recommending patients to see a chiropractor.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 24% of DOs and 29% of MDs have referred a patient themselves to a chiropractor and 82.5% of DOs and 55.4% of MDs accepted referral from chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 18% of DOs and 19% of MDs indicated chiropractors did not send them any clinical information about referred patients.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 73% sent a case report when referring a patient to a chiropractor with 77% sending follow-up clinical information for referred patients. PCPs were also more likely to send x-rays or x-ray reports and other clinical records to other PCPs rather than chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; PCPs in private practice were twice as likely to recommended patients to a chiropractor.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMullin et al., (2011)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Postal questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: \u0026bull; Email invitation was sent to 9000 email addresses of individuals with professional status as a midwife working in the United States. The questionnaire was available for 3 months and IP addresses were tracked to allow each responder to complete the survey only once.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Survey was not validated and exploratory in nature but was pilot tested with two midwives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;187 midwife respondents completed the questionnaire (2.1%)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional training and knowledge of chiropractic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; 30% indicated receiving formal training about chiropractic, 46% indicated receiving some information on chiropractic in their seminars with 75% indicating interest in learning more about chiropractic care.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 99% were aware that chiropractors work with \u0026quot;birthing professionals\u0026quot; and 92% considered themselves knowledgeable about the roles of chiropractors in prenatal care.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 40% were not aware that chiropractic was a licensed profession.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 87% wanted to see more information regarding the evidence of chiropractic management.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eExperience of chiropractic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; 89% have had a professional experience with a chiropractor with 97% of these being a positive experience.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 92% had referred a patient to the chiropractor with 72% indicating referral to specific care of an infant.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 100% perceived chiropractic care as safe during pregnancy with 97% considering it was safe for infants.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIngram et al., (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Post clinical experience survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Physical Therapy students from a south-eastern and mid-western PT program (n\u0026thinsp;=\u0026thinsp;341)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Survey was reviewed by a panel of 5 directors of clinical education unaffiliated with the participating institutions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Therapy students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;229 students competed the survey (67%)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Respondents reported that little was said about chiropractic from tutors but that clinical instructors were reported to be bad mouthing another health profession.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 61% of students heard the badmouthing occurring 2\u0026thinsp;+\u0026thinsp;times.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 22% of these comments were about chiropractic and chiropractors and was one of was one of the top three most mentioned professions that were badmouthed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBowden and Ball (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Class administered questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: 2nd-year graduate students enrolled in either the adult Nursing or Physician Assistant programs (n\u0026thinsp;=\u0026thinsp;95)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: adapted version of Wong and Kopansky-Giles survey (REF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurse Practitioners and Physician Assistant Students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;92 returned questionnaires (97% Overall; 100% form PA and 94% from NPs)\u003c/p\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003cp\u003e\u0026bull; 88% Female, majority of \u0026gt;\u0026thinsp;25 years of age were NPs.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Poor current level of understanding (43%); Majority indicated lack of awareness of current scientific evidence of chiropractic care (75%); Most open to learning more (63%) although 65% said they did not make effort outside of medical school to learn.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Students\u0026thinsp;\u0026gt;\u0026thinsp;25 years of age more likely to have had experience and more likely to be positive.\u003c/p\u003e\n \u003cp\u003e\u0026bull; 45% saw chiropractic as mainstream while 73% saw as CAM.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Participants demonstrated a wide spectrum of correct responses for types of treatment and areas where chiropractors can provide effective treatment.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Survey respondents seemed to lack knowledge that chiropractic care may constitute a range of interventions.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Respondents mostly agreed, however, that chiropractors can provide effective treatment for back pain, neck pain, headaches, shoulder pain, strain/sprain of upper and lower extremities, disc herniation, and peripheral nerve entrapment.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeff et al., (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Sampled whole cohort (n\u0026thinsp;=\u0026thinsp;116) of Physicians and Physicians Assistants working in an integrated health setting with chiropractors.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Survey underwent face validity.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysicians (Ps) and Physician Assistants (PAs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;26 surveys returned (22.4%)\u003c/p\u003e\n \u003cp\u003eResults:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Respondents with less knowledge and awareness of supportive research had lower opinions.\u003c/p\u003e\n \u003cp\u003ePAs had a higher opinion than Ps.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Those who do refer to chiropractors have a high satisfaction with the results of the consult.\u003c/p\u003e\n \u003cp\u003e\u0026bull; The providers who see the most patients per week seem to have the lowest opinion of chiropractic and report the least knowledge of chiropractic.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePenney et al., (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Qualitative analysis as part on multiphase mixed methods study\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Interviews\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Invitation emails sent to 86 PCPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary Care Physicians (PCPs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e: 25 PCP interviews were conducted, distributed nearly evenly among PCPs who were high, medium, and low referrers for acupuncture and/or chiropractic according to plan referral records for both types of services.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral comments about Chiropractic and Acupuncturists (A/C)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; Generally, clinicians had little relationship therefore little communication\u003c/p\u003e\n \u003cp\u003ePhysicians selectively assent to patients who have had previous positive experience and didn\u0026rsquo;t want opioids. Requests denied if contraindicated via guidelines.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Many physicians believe A/C successful because of placebo so held back with patients they felt didn\u0026rsquo;t buy into CAM (however patient focus groups said they would be open even if no previous experience)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physicians didn\u0026rsquo;t feel they knew enough about the modality or the practitioners.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Physicians expressed concern over not being able to provide patients more guidance, seemed anxious about the lack of oversight, and questioned the quality controls for ensuring patient treatment.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Variability amongst A/C providers and quality made choices difficult.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eChiropractic quotes from PCPs only around communication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; The near consensus from both PCPs and A/C providers was there was no effective communication.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Coupled with the negative bias in the occasional reports from patients further eroded PCP confidence in these modalities: \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve actually had less happiness with chiropractors the longer I\u0026rsquo;ve been in practice, just because of what I hear back from patients. [\u0026hellip;] part of it is I don\u0026rsquo;t know who I\u0026rsquo;m referring to. Because it\u0026rsquo;s this sort of contract,\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003epeople that we contract with. [\u0026hellip;] I also don\u0026rsquo;t get notes back from them. So I have no feedback as to what they\u0026rsquo;re doing. Whereas all the Kaiser physical therapists put a note in [the chart]\u0026hellip; And I can review what they\u0026rsquo;ve done, and how many times the patient has gone and the progress they\u0026rsquo;ve made or not made.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBond et al., (2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Survey\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Questionnaire\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Convenience sample across 3rd year PTs in two University programs (U! and U2). n\u0026thinsp;=\u0026thinsp;144 U1 (no chiropractic faculty interaction across health care programs) and 80 at U2 (with chiropractic faculty interaction across healthcare programs)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Validity: Chiropractic attitude questionnaire (CAQ)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Therapy students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse rate: n\u0026thinsp;=\u0026thinsp;165 questionnaires returned (74%)\u003c/p\u003e\n \u003cp\u003eResults of whole cohort: Responses statistically differed between U1 and U2 :\u003c/p\u003e\n \u003cp\u003e\u0026bull; Questions scaled from Strongly agree; Agree; Undecided; Disagree; Strongly disagree.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractic has place in health care (Highest proportion response: Agree)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Information concerning chiropractic profession should be in curriculum (Highest proportion response: Agree)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractic care is evidence based (Highest proportion response: Undecided)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractors perform excessive imaging (Highest proportion response: Undecided)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractic care is patient centred (Highest proportion response: Agree)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Manipulation of the neck is safe (Highest proportion response: Undecided)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractic is effective for non MSK (Highest proportion response: Undecided)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractic can reduce MSK load for PTs (Highest proportion response: Undecided)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractors lack training (Highest proportion response: Disagree)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractors engage in aggressive marketing (Highest proportion response: Undecided)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractors have no role in care of PT patients Highest proportion response: (Disagree)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Chiropractic care breeds dependency (Highest proportion response: Agree)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSalsbury et al., (2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Design: Qualitative\u003c/p\u003e\n \u003cp\u003e\u0026bull; Format: Focus groups and interviews\u003c/p\u003e\n \u003cp\u003e\u0026bull; Sampling: Goal for participant recruitment was to invite all persons who were likely to interact with the chiropractor (patients, family and community members, administrative personnel, and members of the clinical team (medical doctors, nursing staff and therapy staff)). Qualitative analysis was part of a larger organizational case study that used ethnographic methods to explore the process of integrating a chiropractor into an established multidisciplinary team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical doctors\u003c/p\u003e\n \u003cp\u003eNursing staff\u003c/p\u003e\n \u003cp\u003eTherapy staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e: Sixty participants were interviewed: 48 staff members, 6 patients, 4 family members and 2 community members\u003c/p\u003e\n \u003cp\u003eStudy setting was a 62-bed skilled nursing facility located in north-eastern United States\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eThemes were developed from participant responses that centred around qualities, competencies and attitudes that make a chiropractor able to work in a multidisciplinary team. These included\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clinical acumen: to be an expert and experienced health care professional, deep understanding of musculoskeletal conditions and neurological conditions. \u003cem\u003eChiropractors should only use the therapeutic modalities that were likely to improve patients\u0026apos; health status.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; Efficacious treatment: chiropractic care would offer effective, evidence-based options \u003cem\u003eWorries that the delivery of chiropractic care to patients who have had spinal cord injuries could further injure them.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; Teamwork: \u003cem\u003e\u0026quot;We\u0026rsquo;re 95% team oriented here\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; Resourcefulness: \u003cem\u003e\u0026quot;have to be very flexible to work here\u003c/em\u003e,\u0026quot; willingness to change an approach that is not working\u003c/p\u003e\n \u003cp\u003e\u0026bull; Openness to feedback\u003c/p\u003e\n \u003cp\u003ePersonality fit: \u003cem\u003e\u0026quot;will feel comfortable educating the staff\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; Institutional compliance and mission alliance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eIncluded studies were conducted across a wide range of national settings. Study designs were substantially homogenous with a majority using cross-sectional surveys (86%). However, some studies used a range of qualitative approaches including interviews (2%), focus groups (4%) and mixed methods [survey/interview/focus groups/ combinations] (8%). A total of 10,108 participants were included across studies with a broad representation of healthcare professionals both qualified and in training, which included general practitioners (GPs), physicians, doctors, medical doctors, midwives, nurses, physiotherapists, osteopaths, and manual therapists.\u003c/p\u003e\n \u003cp\u003eResults of the quality assessment generally indicated high to moderate quality (Tables\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). For the cross-sectional studies 33% (n\u0026thinsp;=\u0026thinsp;14) fell into the high-quality category with the remaining [n\u0026thinsp;=\u0026thinsp;29] were of moderate quality. Most studies scored high for research question, design, and selection of subjects, whereas sampling that allowed generalisation and sample size calculations were generally not determined. Response rates above 50% were mixed among the studies and most studies failed to provide precision (95% CI) and mitigation of potential confounders. For the 3 qualitative studies 2 were high and 1 was of moderate quality.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003ePopulations and Themes\u003c/h2\u003e\n \u003cp\u003eWe describe the results based on broad categories of health care professionals and attitudinal/perception themes as documented below\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePrimary Health Care Professionals (PHCPs)\u003c/h3\u003e\n\u003cp\u003eStudies that included PHCPs (GPs, physicians, doctors, medical doctors) were synthesised with six broad attitudinal/perception themes emerging: \u003cem\u003eknowledge\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe arbitrarily defined 0\u0026ndash;8, 9\u0026ndash;16 and 17\u0026ndash;24 as low, medium, and high-quality studies respectively.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003eWe arbitrarily defined 0\u0026ndash;5, 6\u0026ndash;10 and 11\u0026ndash;16 as low, medium, and high-quality studies respectively.\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003econcerning chiropractic care or chiropractors, scope of practice, chiropractic care in health systems, interprofessional communication, research base for chiropractic care\u003c/em\u003e and \u003cem\u003eeducation of chiropractors.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of chiropractic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross all included studies exploring PHCPs\u0026rsquo; knowledge of chiropractic care or the chiropractic profession, some level of understanding was frequently reported. However, the depth of knowledge varied ranging from simply having heard about chiropractic[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e] to having moderate to high levels of knowledge[\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. The most comprehensive knowledge was reported in two studies of GPs where 80% and 60% respectively of respondents had heard of or knew of the historic principals of chiropractic care [34], although it was unclear what principals had been referred to. The most frequent percentage of PHCPs possessing \u0026ldquo;some\u0026rdquo; knowledge was around 50%[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. Some studies also reported a desire for further learning about chiropractic interventions, particularly concerning the efficacy of chiropractic care[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e]. Sources by which PHCPs obtained their knowledge were documented in some studies. Most PHCPs reported obtaining their information through medical journals [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e], treatment, relationship with a chiropractor, conversations with other colleagues or friends, family and media coverage [35] or patients [74].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eScope of practice\u003c/em\u003e: The majority of PCHPs perception of chiropractic scope recognised that care provided was beneficial in the management of musculoskeletal [MSK] or neuro-MSK disorders [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]. Studies reported PHCPs identifying specific conditions as legitimate targets of care including mechanical low back pain, neck pain, upper back pain and cervicogenic headaches [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e] although MSK diagnostic skills were not always associated with perceptions of efficacy [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. One study found that some subjects reported being in favour of regular visits to the chiropractor in the prevention of recurrent conditions [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Other conditions that chiropractic care was recognised to provide benefit for included: scoliosis, torticollis, growing pains, headaches, and colic, although the percentage of participants in agreement ranged widely from 20\u0026ndash;46% across the included studies.\u003c/p\u003e\n\u003cp\u003eFor non -MSK conditions some PCHPs disagreed that chiropractic care was efficacious [\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e]. Interestingly contemporary views of some chiropractic students suggest that a tendency toward limitless scope of practice aspirations are associated with \u0026lsquo;magical thinking\u0026rsquo; [\u003cspan class=\"CitationRef\"\u003e67\u003c/span\u003e] Given that other healthcare professionals have strong views condoning a predominantly MSK focused scope of practice, and the evidence for management of non MSK conditions by chiropractors is weak or absent [\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e], addressing variations in chiropractic students views concerning scope of practice may be beneficial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChiropractors in public health systems\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo studies reported PHCPs agreeing that collaboration with a chiropractor, where clinically appropriate, can improve patient health and treatment outcomes [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. White et al [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] reported that 50% of participants agreed that chiropractic care should be included in the UK National Health Service (NHS). Similar attitudes reported in a US study suggest 52% of primary care physicians and obstetrics-gynaecology physicians in a group practice model health maintenance organisation (HMO) agreed chiropractic should be available in such organisations [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eViews differed on how chiropractic care might be integrated. Some PHCPs saw chiropractors as primary care practitioners, whilst others suggested chiropractors required referral from a medical physician to provide care within public health systems [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Some PHCPs perceived chiropractic care as a therapy outside conventional medicine [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e], not conventional medicine [\u003cspan class=\"CitationRef\"\u003e71\u003c/span\u003e] or expressed little interest in sharing care with chiropractors [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]. One study explored PHCPs views attributes that would be important in integrating chiropractic care into wider institutional healthcare teams [\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e]. These included clinical acumen, efficacious treatment, teamwork, resourcefulness, openness to feedback, personality fit, institutional compliance and mission alliance. However, attitudes and behaviour can be in conflict amongst these professionals. For example, a study of PCHPs in the UK, highlighted lack of knowledge concerning indications for use and lack of scientific evidence as a potential barrier despite chiropractic being referred to in the UK by 79% of these participants [\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication between chiropractors and PHCPs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA consistent theme regarding communication between PHCPs and chiropractors emerged from the included studies with PHCPs often perceiving there to be little to no effective communication [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]. Some of the underlying reasons stated were a lack of information provided by chiropractors and the use of confusing or non-standard terminology [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe proportions of PHCPs who had referred to or would consider referring to a chiropractor showed considerable heterogeneity across studies where reported, ranging from 2\u0026ndash;79% of participants [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. Whilst direct referral was the preferred route, alternative routes included informal endorsements or recommendations to patients to seek chiropractic care [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eMotivations behind willingness to refer or recommend patients seemed to be related to knowledge of chiropractic care where PHCPs with such insights were significantly more likely to refer patients [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e]. Studies further reported that patient interest was also a motivating factor, with requests from patients often being looked on as favourable reasons to consider recommendation [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. Other motivating factors included: patients\u0026rsquo; lack of response to conventional medicine [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e], personal beliefs concerning efficacy of chiropractic care, perception of positive results for patients, high PHCP patient loads or absence/exhaustion of other options [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePHCPs\u0026rsquo; attitudes and perceptions regarding referral were not equally distributed amongst demographic or practice categories. Younger doctors, who made up 67% of respondents in included studies were more likely to consider referral [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. In a US study, PHCPs in private practice were twice as likely to recommend patients to a chiropractor than those not in private settings [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. Direct comparison across countries was rare but in one study, PCHPs experiences of chiropractic care for their patients differed between Norwegian (66%) and Swedish (47%) clinicians reporting good experiences of chiropractic care for their patients. [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eFactors that discouraged PHCPs referring included: a lack of knowledge of chiropractic care or absence of positive experience/relationships, as well as fear of litigation and threat to practice reputation [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe research base for chiropractic care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings regarding the perceived efficacy of chiropractic care were heterogeneous. For example, Engel [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e] and Grace [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e] reported 21% and 66% respectively of participants disagreeing with the notion that there was a growing body of evidence supporting the efficacy of chiropractic approaches to care despite these studies being published at a similar time. Other surveys reported positivity regarding evidence for effectiveness where PCHPs considered chiropractic practice to be generally primarily evidence based [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, the proportion of respondents aligning to this view varied considerably (12\u0026ndash;70%) [ 48, 22, 30, 45, 46].\u003c/p\u003e\n\u003cp\u003eViews concerning perceived adverse effects and/or potential harm were also heterogenic. White et al [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] Pirotta [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] and Grace [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e] reporting 13%, 38% and 75% of participants respectively showing concern that chiropractic care maybe occasionally harmful. This also varied across national settings where US based orthopaedic surgeons were more likely to feel that neck manipulation was safe in comparison to their Canadian colleagues [\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChiropractic education and skills\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were mixed opinions regarding perceptions related to chiropractic education and skills. Negative perceptions included Grace [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e] where one quarter of respondents were concerned about the credibility of the educational background of chiropractors, whilst Engel [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e] reported 70% of PHCPs believing that chiropractic education was not primarily evidence based. More positively, Westin [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e] found that 80% of their Scandinavian study PCHPs agreed that the education of chiropractors was satisfactory while Canadian orthopaedic surgeons felt chiropractors had adequate education [\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eNon-Medical Health Care Professionals (NMHPs)\u003c/h3\u003e\n\u003cp\u003eStudies exploring attitudes and perceptions of NMHPs included midwives, nurses, physiotherapists, osteopaths, and manual therapists. Similar themes (\u003cem\u003eknowledge concerning chiropractic care or chiropractors\u003c/em\u003e, \u003cem\u003echiropractic care in health systems\u003c/em\u003e and \u003cem\u003ethe education of chiropractors\u003c/em\u003e) emerged as for PCHPs apart from scope of practice, research base and interprofessional communication which were largely absent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of chiropractic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudies included reported midwives, osteopaths, physiotherapists, and manual therapists had some knowledge of chiropractic. Langworthy [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e] noted that two thirds of osteopaths, manual therapists and physiotherapists had heard something about chiropractic. In midwifery there were high levels of knowledge reported where 98% were aware that chiropractors work with midwives, 92% considered themselves knowledgeable of the role of chiropractic within prenatal care, 59% knew that the chiropractic profession was a licensed profession and 75% showed interest in learning more about the profession [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eSources of information used by NMHPs to gain knowledge of chiropractic were heterogenic. For example, formal education as to the role of chiropractic in healthcare varied from 10% of physiotherapists, 25\u0026ndash;33% of manual therapists and osteopaths and 30% of midwives [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e]. In addition, one third of physiotherapists, osteopaths and manual therapists gained their knowledge through talking to their own patients. Furthermore, despite being the least preferred method of learning, 20% of physiotherapists and osteopaths obtained information from media outlets with the preferred method through scientific journals [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]. Finally, 46% of midwives in one study also received information from attending seminars [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eViews concerning the efficacy and safety of chiropractic care was explored amongst midwives and nurses. For the midwifery study, 100% of participants agreed that chiropractic is safe during pregnancy and 96% agreed that chiropractic is also safe for infant care, although, responder bias may be significant here due to very low response rate [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChiropractic in public healthcare systems\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eViews concerning inclusion in healthcare systems included perceiving the chiropractic profession as direct competition, with half perceiving the profession to be best described as a complementary alternative therapy. These respondents were generally unsupportive of statutory registration for the profession, but this was over 2 decades ago [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]. More positively, most physiotherapists, osteopaths and manual therapists agreed that better communication and collaboration between professionals would likely be better for patient care [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]. Interestingly in the single study concerning midwifery, 88.8% of respondents reported having worked with chiropractors professionally with 97% of this cohort reporting a positive experience. Ninety two percent of this cohort also reported having referred to chiropractors for infant care [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e]. However, the return rate for the survey was only 2.1% with responder bias likely to be significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChiropractic education and skills\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA single study reported that 50% of physiotherapists and 100% of osteopaths felt chiropractors were skilled professionals [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003ePrimary health care students (PHCS)\u003c/h2\u003e\n \u003cp\u003eStudies concerning attitudes and perceptions of PHCS identified a single common theme centered on lack of knowledge of current chiropractic care. Respondents included 1,200 medical students from UK, Australia, and Canada in 4 separate studies. Here the primary theme was around \u003cem\u003eknowledge concerning chiropractic care or chiropractors\u003c/em\u003e.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of chiropractic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMost participants indicated poor knowledge and understanding of chiropractic care [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]. Perkin [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e] compared GPs, medical doctors and medical students and reported that GPs were statistically more knowledgeable than both MDs and medical students, with medical students being the least knowledgeable.\u003c/p\u003e\n \u003cp\u003eIn one study, sources of knowledge for PHCS were from informal sources such as conversations with friends, small groups, student clubs and lecturers [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]. Some participants noted these experiences often painted a negative impression of chiropractic with most participants unable to recall positive descriptions concerning chiropractic by academic staff.\u003c/p\u003e\n \u003cp\u003eThis study further explored PHCS perceived knowledge of a chiropractors\u0026rsquo; scope of practice, and showed half of medical students surveyed were undecided or had no knowledge, associated with apprehension concerning referring. When asked about how medical students perceived chiropractic care within the healthcare landscape, 61.6% of participants perceived chiropractic as a CAM profession [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eDespite most participants having limited knowledge of chiropractic care, interest in learning more was expressed by 67% of participants. These students expressed particular interest in learning what conditions chiropractors commonly treat, with 83.9% agreeing that interprofessional education is important [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eIn an Australian study by Hopper et al [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e], 84% of respondents indicated chiropractors should be on a professional register whilst only 48% felt they should be remunerated through the national system.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eNon-Medical healthcare students (NMHCS)\u003c/h2\u003e\n \u003cp\u003eRespondents in this cohort included students in various years of their education studying nursing [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e] or physiotherapy/physical therapy [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]. Common themes emerged as in other cohorts including \u003cem\u003eknowledge concerning chiropractic care or chiropractors\u003c/em\u003e, \u003cem\u003echiropractic in public healthcare systems, chiropractic education a skills\u003c/em\u003e and \u003cem\u003ethe chiropractic research base\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of chiropractic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe knowledge students possessed concerning chiropractic care showed heterogeneity across studies. Amongst physiotherapy students in South Africa in 1st and final years, 58% and 62% respectively showed a good level of knowledge [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]. In contrast, within this same cohort, 38% of 1st year students and 49% final year students thought \u0026ldquo;chiropractors do the same thing as physios.\u0026rdquo; In contrast nursing students showed a poor level of understanding of the profession despite recognising a chiropractor\u0026rsquo;s scope of practice as regularly treating patients with back pain, neck pain, headaches, shoulder pain, strain/sprain of extremities, disc herniations, and peripheral nerve entrapments [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e]. When asked about interest in learning about the profession, 65% responded that they wouldn\u0026rsquo;t try to learn outside of school, with most students having no personal interest in learning about chiropractic care. In contrast, when physiotherapy students were asked about their interest towards learning about the profession, 55.3% agreed that chiropractic information should be in the curriculum [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eChiropractic in public healthcare systems\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eQuestions regarding chiropractic care as delivered within the wider public health system were explored in some studies with 60.3% of physical therapy students agreeing that chiropractic has a place in healthcare [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e]. Where chiropractors and physiotherapists attitudes towards each other were explored, 76% of 1st year physiotherapy students and 84% of final year students perceived chiropractors as direct competition, with some believing chiropractors delivered similar care to physiotherapists. Interestingly as these students progressed through undergraduate education, interest in referring to chiropractors decreased. Moreover, and somewhat contradictory, 43% of 1st year students and 53% final year students were happy to work closely with chiropractors in patient care [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]. Generally, attitudes concerning chiropractic care as integrated into wider healthcare systems showed considerable variation with students seeing chiropractic as a complementary or alternative medicine or mainstream [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eResearch base for chiropractic care\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEvidence for chiropractic care emerged as an issue for physical therapy students where 46.3% were undecided as to whether chiropractic is evidence-based and 47.8% were undecided that chiropractic can provide effective care for non-MSK patients [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e]. In exploring other perceptions, 38.2% of the same cohort believed that manipulation of the neck is generally safe, and 43.4% were undecided whether chiropractic care bred patient dependency. However, a somewhat contradictory 57.1% of respondents felt chiropractors provide patient-centered care leading. In contrast, Naidoo and Buhler [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e] found 25% and 50% of 1st and final year students respectively, who have had previously consulted a chiropractor, agreed that chiropractic care was effective. Nursing students reported a lack of awareness of the scientific evidence on chiropractic care [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e]. Overall, considerable variation and potential cognitive dissonance may exist amongst these cohorts\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eChiropractic education and skills\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEducation and training of chiropractors was briefly mentioned in the study conducted by Bond et al [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e] where only 7% of physical therapy students agreed with the proposition that chiropractors lack sufficient training.\u003c/p\u003e\n \u003cp\u003eInterestingly a single study explored unconscious attitudes and perceptions amongst non-medical students using an implicit association test. Here a list of words identified in a survey of physiotherapy students that best described chiropractic or medicine as determined by these students was subsequently used in a word association test with negative or positive terms. The authors reported that the word association task took statistically significantly longer to complete when \u0026ldquo;chiropractic\u0026rdquo; was paired together with \u0026ldquo;positive\u0026rdquo; terms than when \u0026ldquo;chiropractic\u0026rdquo; was paired together with \u0026ldquo;negative\u0026rdquo; terms uncovering potential subconscious negative bias toward chiropractic [\u003cspan class=\"CitationRef\"\u003e64\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eSecondary analysis over time within countries\u003c/h2\u003e\n \u003cp\u003eThere was considerable heterogeneity of samples, professions and survey instruments between national settings and over time, although research designs were generally homogeneous. We attempted to identify any trends over time by grouping studies by national jurisdiction to mitigate differences in cultural, fiscal, and legislative settings. Table\u0026nbsp;5 shows summary comments within each country and where only one study exists a general comment summarizing the study is made. Although there are limitations to this approach, we identified a general absence of overt positive change in attitudes and perceptions over time in countries with more than one study. Indeed, where trends could be robustly identified via repetition of the same survey, either negative sentiment and perceptions remained [\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e58\u003c/span\u003e] or attitudes and cooperation worsened [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Consistent themes emerged over time around a continued lack of knowledge concerning chiropractic practice, education, and scientific evidence, particularly amongst medical personnel. Generally, (although with exceptions) the literature reviewed here suggest referrals between most chiropractors and medical doctors in most national jurisdictions remains low and that has persisted over time.\u003c/p\u003e\n \u003cp\u003eImportantly, where good relationships within clinical or educational institutions were present or amongst individual health care professionals and chiropractors, there was evidence of increased positivity and cooperation. In addition, where greater knowledge was present this was also often associated with more positive attitudes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review has summarised the published data concerning attitudes and perceptions of a wide range of health care professionals and health care students toward chiropractors and chiropractic care.\u003c/p\u003e \u003cp\u003eMajor themes regarding \u003cem\u003eknowledge concerning chiropractic care or chiropractors, scope of practice, chiropractic in public healthcare systems, interprofessional communication, the research base for chiropractic care\u003c/em\u003e, and the \u003cem\u003eeducation of chiropractors\u003c/em\u003e emerged. These themes appeared in varying degrees across all groups surveyed but not all themes were present in every group.\u003c/p\u003e \u003cp\u003eNot surprisingly those professions more closely aligned to the scope of practice commonly associated with chiropractors [musculoskeletal] tended to have more knowledge and broadly more acceptance [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], whereas participants with limited contact with chiropractors or chiropractic patients were less informed [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePositively, perception of the potential harm associated with chiropractic care appears to have reduced over time. However, some themes have persisted and may be impacted by a lack of consistent and accurate information about chiropractic in the minds of participants. For example, lack of knowledge amongst PHCPs in included studies for example, appears to be related to a general lack of working together despite clinicians often expressing the importance of collaboration [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] However, where other health professionals came into contact with chiropractors within their day-to-day work, attitudes shifted positively. [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConcerning evidence, Neff [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] reported that physicians and physician-assistants that had lower knowledge of supportive research for chiropractic care, also had lower opinions of the profession generally, so a paucity of knowledge here also may have important implications for attitudes and perceptions more widely.\u003c/p\u003e \u003cp\u003eDoubts concerning the adequacy of chiropractic education also appears to have persisted [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] although in one study such doubts differed for chiropractors graduating from different institutions. For example, those graduating from an institution in the USA being perceived as far less adequate than those from a chiropractic program in Canada [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn non-medical healthcare participants similar themes arose but in physiotherapists, added to perceived competition [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. These professionals often had good knowledge of the chiropractic profession although the sources of this knowledge were diverse and did not include the chiropractic profession themselves. Despite some studies reporting lack of support of chiropractors working within the health systems, generally there was consensus around cooperation and multi-professional patient management.\u003c/p\u003e \u003cp\u003eAttitudes and perceptions were however somewhat malleable, where more positive attitudes seemed to be generated post an educational intervention shifted attitudes toward the positive [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Here, after the intervention there was a statistically significant increase in number of attitude-positive responses compared to the prequestionnaire. The authors conclude that formal education within medical curricula may help to mitigate hidden curriculum issues and support collaboration between medical and chiropractic providers post-graduation.\u003c/p\u003e \u003cp\u003eSuboptimal communication between chiropractors and other health care professionals stood out as a particular factor with achievable solutions. Lack of sufficient information about referred patients provided by chiropractors was cited as a problem in some studies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Another element related to communication was chiropractors\u0026rsquo; use of confusing or non-standard terminology [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These factors have been explored in both Australia and the UK with evidence of a continued prevalence of chiropractic specific terminology on the chiropractors\u0026rsquo; websites [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e An increase in better communication might usefully be addressed education settings, as well as in guidelines from regulators.\u003c/p\u003e \u003cp\u003eProfessional identity has long been debated within the chiropractic profession [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Some chiropractors see themselves as primary care [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e], but this review demonstrates that many physicians do not consider them so. Here, educational interventions for other health care professionals including integrating knowledge of chiropractic care within curricula of medical and non-medical health care professionals may prove useful.\u003c/p\u003e \u003cp\u003eHealthcare students identified fewer, but similar themes centring predominantly on a lack of knowledge of the profession, particularly in medical students with sources of knowledge ranging from anectodical conversations amongst students themselves to medical faculty, who were perceived as generally less than positive [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Despite this there was a desire to learn more in addition to support for interprofessional cooperation. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe implications for the chiropractic profession of the insights provided by this literature review ultimately rests on where the profession desires to go, how it aspires to be identified and in what capacity it wishes the existing healthcare community to understand and interact with chiropractors. It is not disputed that interprofessional communication and working relationships between health care professionals for the benefit of their mutual patients is both desired by patients and increases the likelihood of higher satisfaction and better outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Further research would usefully explore the attitudes and aspirations of the chiropractic profession in this regard. For example, the profession as a community may feel they do not desire to work in the wider healthcare landscape having curated successful practices at least financially, without having to do so. Such isolation was impacted early on in chiropractic history through sustained persecution by the medical profession in the US where to be \u0026lsquo;\u003cem\u003eseparate and distinct to medicine\u0026rsquo;\u003c/em\u003e had kept early chiropractors out of jail. However, these times have passed, and the continued isolation of the profession has been contemporarily paraphrased as \u0026lsquo;\u003cem\u003eseparate and extinct\u0026rsquo;.\u003c/em\u003e Perhaps such desires from a vocal part of the profession to cleave to this separateness may not be sustainable in the long term. On the other hand, if a majority desire to forge better and more cohesive relationships with other health care professionals, this review suggests educational interventions may be particularly efficacious in underpinning increased knowledge and a willingness to work toward mutual support of their patient communities. This particularly so at undergraduate level where perhaps interprofessional learning in joint classrooms may facilitate a \u003cem\u003elearn together, work together\u003c/em\u003e mindset. Clearly however there must be willingness from both sides to corporate better. Where such models exist, they may constitute general exemplars of structures and cultures where this works [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis review is, as far as we know, the first to comprehensively review the large number of studies that have surveyed other professions as to attitudes and perceptions of chiropractic care and chiropractors. We chose to not limit the date which meant we were able to explore any changes of attitude over long periods, particularly where identical surveys were repeated at different time point in some jurisdictions, although this was limited by several factors as discussed below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are clear limitations to this review. Firstly, we chose not to limit the period of the publications which resulted in a large time window within which the results were available where issues initially present in older studies may have been mitigated in more recent surveys. Our attempt to explore changes in perceptions over time was clearly limited by study heterogeneity form one study to the next, except in just a few cases where surveys were repeated by the same authors.\u003c/p\u003e \u003cp\u003eSurvey instruments were also heterogenic although most had attempted some degree of face validity or had created surveys based on previous literature. However, the degree with which detail concerning attitudes could be extracted was varied with one study providing only a single question concerning attitudes regarding the chiropractic profession [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Notwithstanding, such heterogeneity in the wording and design of surveys, and within national jurisdictions would suggest caution in interpreting any observed similarities or differences between studies results. In addition, only a third of studies were deemed high quality as judged by the risk of bias assessment in the review with the remaining two thirds being medium quality. In the absence of a sub analysis based on quality, the reporting of high and medium quality studies as a homogenous group may have confounded attempts to summarise themes.\u003c/p\u003e \u003cp\u003eLastly, not all national jurisdictions were represented equally with Australia, Canada, USA and UK dominating the data set. We attempted to mitigate this by presenting characteristics of studies within national jurisdictions and summarising any observed changes within these jurisdictions over time. However, this observational summary may not be as robustly representative as desired to confidently identify changes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this review suggest that a consistent issue impacting attitudes and perceptions of other professions toward chiropractic care or chiropractors is a general lack of knowledge concerning key aspects of the chiropractic profession. Where knowledge was higher, generally attitudes and perceptions were more positive and where educational interventions were used to increase knowledge such efforts generated improved perceptions. The solution to this knowledge gap may be multifactorial and include efforts to produce accessible and digestible quality information concerning the themes highlighted in this review and/or greater visibility of the chiropractic profession within diverse healthcare settings or through greater shared management of patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eNot applicable\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eNot applicable\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eData sharing not applicable to this article as no datasets were generated or analysed during the current study.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe authors declare that they have no competing interests.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThis study was funded by a grant from the Chiropractic Research Council, UK. The funder had no role in the design of the study, analysis, interpretation of data and in writing the manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDN designed the study and conducted scoping searches. AN and DN completed all searches whilst AN, KY and JF applied the exclusion/inclusion criteria with AN and DN assessing quality and risk of bias. AN, DN, MH and MS completed the draft manuscripts whilst all authors contributed to the final text and approved the manuscript for submission.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eNot applicable\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReggars JW (2011) Chiropractic at the crossroads or are we just going around in circles? Chiropr Man Th 19:11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeeker WC, Haldeman S (2002) Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 136(3):216\u0026ndash;227\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker BF (2016) The new chiropractic. Chiropr Man Th 24:26\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D (2008) Chiropractic and public health: Current state and future vision. J Manip Physiol Ther 31:397\u0026ndash;410\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePollard H (2021) Reframing a debate in chiropractic. Chiropr Man Th 29:44\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGregor M, Puhl AA, Reinhart C, Injeyan HS, Soave D (2014) Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey. BMC Complement Altern Med 14:51\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGliedt JA et al (2021) Evaluation of United States chiropractic professional subgroups: A survey of randomly sampled chiropractors. BMC Health Serv Res 21(1):1\u0026ndash;1049\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026iacute;slason HF, Salminen JK, Sandhaugen L, Storbr\u0026aring;ten AS, Versloot R, Roug I, Newell D (2019) The shape of chiropractic in Europe: A cross-sectional survey of chiropractor\u0026rsquo;s beliefs and practice. Chiropr Man Th 27:16\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStochkendahl MJ, Rezai M, Torres P, Sutton D, Tuchin P, Brown R, C\u0026ocirc;t\u0026eacute; P (2019) The chiropractic workforce: a global review. Chiropr Man Th 27:1\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHCPC [2021] (2022) Which professions do HCPC regulate? Health \u0026amp; Care Professions Council. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hcpc-uk.org/public/which-professions-do-hcpc-regulate/\u003c/span\u003e\u003cspan address=\"https://www.hcpc-uk.org/public/which-professions-do-hcpc-regulate/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed November 30\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS England. The 14 allied health professions. London: NHS (2022) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.england.nhs.uk/ahp/role/\u003c/span\u003e\u003cspan address=\"https://www.england.nhs.uk/ahp/role/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReiter HH (1965) Some physicians\u0026rsquo; perceptions of chiropractors, osteopaths, and podiatrists. Percept Mot Skills 20(3suppl):1167. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e8.https://doi.org/10.2466/pms.1965.20.3c.1167\u003c/span\u003e\u003cspan address=\"8.10.2466/pms.1965.20.3c.1167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToloui-Wallace J, Forbes R, Thomson OP, Setchell J (2022) When worlds collide: Experiences of physiotherapists, chiropractors, and osteopaths working together. Musculoskelet Sci Pract. ;60\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Neill SF, Konner MB, Fejer R, Vesterager SV (2020) Establishing a residency program for a chiropractic specialty in a public hospital system: Experiences from Denmark. J Chiropr Educ 34(2):164\u0026ndash;171\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurdick R, Corcoran KL, Zhao X et al (2022) The rate of use of Veterans Affairs chiropractic care: a 5-year analysis. Chiropr Man Th. ;30(4)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLouwe J, Myburgh C (2007) The knowledge and perception of general practitioners about chiropractic as a factor that may influence inter-professional communication: a South African perspective. J Interprof Care 21(2):221\u0026ndash;224\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Board of Chiropractic Examiners. Practice analysis of chiropractic 2020. Greeley (CO): NBCE (2020) Available from: MyNBCE - The Practice Analysis of Chiropractic 2020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJ\u0026oslash;rgensen P (2014) Kiropraktikkens historie i Danmark. Syddansk Universitetsforlag, Odense, pp 195\u0026ndash;248\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyburgh C (2014) A qualitative exploration of key informant perspectives regarding the nature and impact of contemporary legislation on professional development: a grounded theory study of chiropractic in Denmark. J Manipulative Physiol Ther 37(6):383\u0026ndash;395\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeneral Chiropractic Council (2021) Registrant Survey 2020 \u0026ndash; Main Report. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gcc-uk.org/assets/publications/GCC_Registrant_Survey_2020_-_main_report_final.pdf\u003c/span\u003e\u003cspan address=\"https://www.gcc-uk.org/assets/publications/GCC_Registrant_Survey_2020_-_main_report_final.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry R, Dowrick CF (2000) Complementary medicine and general practice: an urban perspective. Complement Ther Med 8(2):71\u0026ndash;75\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry R, Dowrick C, Ernst E (2014) Complementary medicine and general practice in an urban setting: a decade on. Prim Health Care Res Dev 15(3):262\u0026ndash;267\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimpson JK, Young KJ (2020) Vitalism in contemporary chiropractic: a help or a hinderance? Chiropr Man Th 28:35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12998-020-00307-8\u003c/span\u003e\u003cspan address=\"10.1186/s12998-020-00307-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCentre for Evidenced Based Management Critical Appraisal of a Survey. Available at this link \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-July-2014-1-v2.pdf\u003c/span\u003e\u003cspan address=\"https://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-July-2014-1-v2.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed March 2021]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N, Roen K, Duffy S (2006) Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme. Lancaster University, Lancaster. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.13140/2.1.1018.4643\u003c/span\u003e\u003cspan address=\"10.13140/2.1.1018.4643\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCentre for Evidenced Based Management Critical Appraisal of a Survey. Available at this link \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-July-2014-1-v2.pdf\u003c/span\u003e\u003cspan address=\"https://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Cross-Sectional-Study-July-2014-1-v2.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed March 2021]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCentre for Evidence Based Medicine Critical Appraisal Qualitative. Available at this link \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Qualitative-Study-July-2014-1-v2.pdf\u003c/span\u003e\u003cspan address=\"https://cebma.org/assets/Uploads/Critical-Appraisal-Questions-for-a-Qualitative-Study-July-2014-1-v2.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed March 2021]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThondhlana SS, Kell CM, Pillay JD (2021) General practitioners\u0026rsquo; knowledge, perception and utilization of services in the chiropractic management of musculoskeletal disorders in Harare, Zimbabwe. Afr J Phys Activity Health Sci 27(1):72\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBusse JW, Jim J, Jacobs C, Ngo T, Rodine R, Torrance D, Kulkarni AV, Petrisor B, Drew B, Bhandari M (2011) Attitudes towards chiropractic: an analysis of written comments from a survey of North American orthopaedic surgeons. Chiropr Man Th 19(1):1\u0026ndash;7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePirotta MV, Farish SJ, Cohen MM, Kotsirilos V (2000) Complementary therapies: have they become accepted in general practice? Med J Aust 172(3):105\u0026ndash;109\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavidson E (2007) Experience with and attitudes towards chiropractors treating children among GPs in Grampian, Scotland\u0026mdash;a survey. Focus Altern Complement Ther 12:18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePreston-Thomas A, Van den Bergh LA, Maxwell L (1993) Referral for Manual Therapy: A Survey Of General Medical Practitioners In The Auckland Area. N Z J Physiother 21:25\u0026ndash;28\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan PS, Wong MM (2004) Physicians and complementary-alternative medicine: training, attitudes, and practices in Hawaii. Hawaii Med J. ;63(6)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerkin MR, Pearcy RM, Fraser JS (1994) A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine. J R Soc Med 87(9):523\u0026ndash;525\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrussee WJ, Assendelft WJ, Breen AC (2001) Communication between general practitioners and chiropractors. J Manip Physiol Ther 24(1):12\u0026ndash;16\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngel RM, Beirman R, Grace S (2016) An indication of current views of Australian general practitioners towards chiropractic and osteopathy: A cross sectional study. Chiropr Man Th 24:1\u0026ndash;0\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNewton-Leo L, King-Isaacs D, Lichti J (1994) Knowledge and opinions of Downsview physicians regarding the chiropractic profession. J Can Chiropr Assoc 38(2):90\u0026ndash;95\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWestin D, Tandberg T, John C, Ax\u0026eacute;n I (2013) GPs opinions and perceptions of chiropractic in Sweden and Norway: a descriptive survey. Chiropr Man Th 21:1\u0026ndash;7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMainous AG 3rd, Gill JM, Zoller JS, Wolman MG (2000) Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med 9(5):446\u0026ndash;450\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite AR, Resch KL, Ernst E (1997) Complementary medicine: use and attitudes among GPs. Fam Pract 14(4):302\u0026ndash;306\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGordon NP, Sobel DS, Tarazona EZ (1998) Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization. West J Med 169(3):153\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreene BR, Smith M, Allareddy V, Haas M (2006) Referral patterns and attitudes of primary care physicians towards chiropractors. BMC Complement Altern Med 6(1):1\u0026ndash;1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePenney LS, Ritenbaugh C, Elder C, Schneider J, Deyo RA, DeBar LL (2016) Primary care physicians, acupuncture and chiropractic clinicians, and chronic pain patients: a qualitative analysis of communication and care coordination patterns. BMC Complement Altern Med 16:1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKier A, George M, McCarthy PW (2013) Survey based investigation into general practitioner referral patterns for spinal manipulative therapy. Chiropr Man Th 21(1):18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerhoef MJ, Sutherland LR (1995) Alternative medicine and general practitioners: Opinions and behaviour. Can Fam Physician 41:105\u0026ndash;1011\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerhoef MJ, Page SA (1996) Physicians\u0026rsquo; perspectives on chiropractic treatment. J Can Chiropr Assoc. ;40(4)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWardle JL, Sibbritt DW, Adams J (2013) Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia. Chiropr Man Th 21:1\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrace S, Engel R, Jalsion I (2018) Themes underlying Australian general practitioner views towards chiropractic and osteopathy: An assessment of free text data from a cross-sectional survey. \u003cem\u003eEvidence-Based Complementary and Alternative Medicine\u003c/em\u003e. ;2018\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLangworthy JM, Smink RD (2000) Chiropractic through the eyes of physiotherapists, manual therapists, and osteopaths in The Netherlands. J Altern Complement Med 6(5):437\u0026ndash;443\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMullin L, Alcantara J, Barton D, Dever L (2011) Attitudes and views on chiropractic: a survey of United States midwives. Complement Ther Clin Pract 17(3):13540\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarner MJ, Birmingham M, Aker P, Moher D, Balon J, Keenan D, Manga P (2008) Developing integrative primary healthcare delivery: Adding a chiropractor to the team. Explore 4(1):18\u0026ndash;24\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong JJ, Di Loreto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles D (2013) Assessing the attitudes, knowledge, and perspectives of medical students to chiropractic. J Can Chiropr Assoc 57(1):18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHopper I, Cohen M (1998) Complementary therapies and the medical profession: A study of medical students\u0026rsquo; attitudes. Altern Ther Health Med 4(3):68\u0026ndash;73\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowden BS, Ball L (2016) Nurse practitioner and physician assistant students\u0026rsquo; knowledge, attitudes, and perspectives of chiropractic. J Chiropr Educ 30(2):114\u0026ndash;120\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBond BM, Dehan J, Horacek M (2018) Does interprofessional interaction influence physical therapy students\u0026rsquo; attitudes toward chiropractic? J Can Chiropr Assoc 62(3):143\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaidoo N, B\u0026uuml;hler L (2009) The perceptions, attitudes and knowledge of physiotherapy and chiropractic students regarding each other\u0026rsquo;s professional practice. S Afr JPhysiother 65(2):32\u0026ndash;37\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBusse JW, Jacobs C, Ngo T, Rodine R, Torrance D, Jim J, Kulkarni AV, Petrisor B, Drew B, Bhandari M (2009) Attitudes toward chiropractic: a survey of North American orthopedic surgeons. Spine 34(25):2818\u0026ndash;2825\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBusse JW, Pallapothu S, Vinh B, Lee V, Abril L, Canga A, Riva JJ, Viggiani D, Dilauro M, Harvey MP, Pag\u0026eacute; I, Bhela AK, Sandhu S, Makanjuola O, Hassan MT, Moore A, Gauthier CA, Price DJ (2021) Attitudes towards chiropractic: a repeated cross sectional survey of Canadian family physicians. BMC Fam Pract\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong JJ, Di Loreto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles D (2014) Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after an educational intervention. J Chiropr Educ 28(2):112\u0026ndash;122\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunnisett A, Cunliffe C (2012) Chiropractic treatment as a primary care intervention for better musculoskeletal health in the aging population in the United kingdom: an opinion and positioning paper. Front Physiol 3:87\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones-Harris AR (2010) Are chiropractors in the uk primary healthcare or primary contact practitioners? a mixed methods study. Chiropr Man Th 18:28\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIngram D, Flom-Meland C, Hosford C, Grubb R, Nicholson CC, Terry B (2013) Badmouthing of health care professionals. J Phys Therapy Educ 27(2):16\u0026ndash;22\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eŽivčić D, Racz A, Naletilić D (2014) Differences in attitudes towards/beliefs on complementary and alternative medicine witnessed between physiotherapists, nurses, paramedics, and physicians. Afr J Tradit Complement Altern Med 11(6):57\u0026ndash;65\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung CL, Manga J, McGregor M, Michailidis C, Stavros D, Woodhouse LJ (2012) Interprofessional collaboration and turf wars: how prevalent are hiddenattitudes? J Chiropr Educ 26(1):3\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Luca K et al (2018) The identity, role, setting, and future of chiropractic practice: A survey of Australian and New Zealand chiropractic students. \u003cem\u003eJChiropractic Educ\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlucina TT et al (2020) Moving towards a contemporary chiropractic professionalidentity. \u003cem\u003eComplementary Therapies in Clinical Practice\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInnes S, Goncalves G, Leboeuf-Yde C (2022) Who are the chiropractic students favouring a limitless scope of practice? Exploring the relationship with personality, magical thinking, and academic achievement. Chiropr Man Th 30:30\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eC\u0026ocirc;t\u0026eacute; P, Hartvigsen J, Ax\u0026eacute;n I et al (2021) The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature. Chiropr Man Th 29:8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKvammen OC, Leboeuf-Yde C (2014) The chiropractic profession in Norway 2011. Chiropr Man Th 22:44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12998-014-0044-5\u003c/span\u003e\u003cspan address=\"10.1186/s12998-014-0044-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeff S, DC M, Jordan RJ (2016) Physician \u0026amp; Physician Assistant Attitudes and Referral Habits Concerning Chiropractic. J Acad Chiropr Orthop 13(2):1\u0026ndash;11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoynton L, Dowell A, Dew K, Egan T (2006) General practitioners\u0026rsquo; attitudes toward [and use of] complementary and alternative medicine: a New Zealand nationwide survey. N Z Med J 119(1247):U2360\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalsbury SA, Vining RD, Gosselin D, Goertz CM (2018) Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team. Chiropr Man Th 26:29\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt K, Jacobs PA, Barton A (2002) Cross-cultural differences in GPs\u0026rsquo; attitudes towards complementary and alternative medicine: a survey comparing regions of the UK and Germany. Complement Ther Med 10(3):141\u0026ndash;147\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeis CA, Stuber K, Barrett J, Greco A, Kipershlak A, Glenn T, Desjardins R, Nash J, Busse J (2016) Attitudes toward chiropractic: a survey of Canadian obstetricians. J Evid Based Complement Altern Med 21(2):92\u0026ndash;104\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung KJ (2020) Words matter: the prevalence of chiropractic-specific terminology on Australian chiropractors\u0026rsquo; websites. Chiropr Man Th 28:18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung KJ, Theroux J (2021) Prevalence of Chiropractic-Specific Terminology on Chiropractors\u0026rsquo; Websites in the United Kingdom with Comparison to Australia: An Analysis of Samples. J Chiropr Humanit 28:15\u0026ndash;21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHumphreys BK, Peterson CK, Muehlemann D, Haueter P (2010) Are Swiss chiropractors different than other chiropractors? Results of the job analysis survey. J Manipulative Physiol Ther 33(7):519\u0026ndash;535\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHumphreys BK, Peterson CK (2016) The Swiss Master in Chiropractic Medicine Curriculum: Preparing Graduates to Work Together With Medicine to Improve Patient Care. J Chiropr Humanit 11(1):53\u0026ndash;60\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchot E, Tummers L, Noordegraaf M (2020) Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. J Interprof Care 34(3):332\u0026ndash;342\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHofstetter L, H\u0026auml;usler M, M\u0026uuml;hlemann M et al (2022) Musculoskeletal healthcare at a Swiss university hospital chiropractic medicine outpatient clinic in 2019: a health services research study. Chiropr Man Th ;30 (7)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePage MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 3 and 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Health Sciences University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chiropractic practice, Chiropractors, Attitudes, Perceptions, Healthcare professionals","lastPublishedDoi":"10.21203/rs.3.rs-5803290/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5803290/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eChiropractic care often exists outside of national healthcare systems, with exceptions in some national settings. This situation has led to suboptimal interprofessional communication and referral, with implications for the provision of appropriate and efficient care. To find solutions, the attitudes and perceptions of other professions must be better understood. We conducted a systematic review to assess other healthcare professionals\u0026rsquo; perceptions and attitudes towards chiropractors and chiropractic care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe review was registered with PROSPERO (CRD42023403381). Reporting was guided by the PRISMA statement. A search was carried out on PubMed, CINAHL, AMED, Index of Chiropractic Literature (ICL) and MEDLINE in Jan 2021 and updated on Jan 2022, February 2023 and June 2024. We included qualitative and quantitative study designs, focusing on healthcare professionals' attitudes toward and perceptions of chiropractic. Methodological quality was assessed using the Centre for Evidence Based Medicine tools for qualitative and cross-sectional survey studies\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe search retrieved 245 articles, of which 43 were included for review. Studies had been conducted across multiple national jurisdictions A total of 10,108 participants were included across the studies, including primary and secondary healthcare professionals as well as healthcare students. Issues identified with influencing opinions of chiropractic practice included participants\u0026rsquo; knowledge of chiropractic methods, scope of practice, interprofessional communication, research base, and education. While some participants reported a perception of positive clinical outcomes associated with chiropractic care, communication between healthcare professionals and chiropractors was often lacking. Attitudes towards chiropractic varied, with factors like knowledge, patient interest, and referrals influencing perceptions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo improve interprofessional attitudes and perceptions, the chiropractic profession might prioritise increased communication and information access concerning contemporary chiropractic care with other health care professions including educational interventions. Mitigation of a persistent lack of reliable information may improve how the profession is perceived in general, reduce misinformation and increase the likelihood that patients will receive the joined-up care they need.\u003c/p\u003e","manuscriptTitle":"Attitudes and perceptions of health care professionals concerning chiropractors and chiropractic practice: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-13 13:11:12","doi":"10.21203/rs.3.rs-5803290/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"04c29091-3e94-4801-8ed9-18166dbaf98b","owner":[],"postedDate":"January 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T13:11:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-13 13:11:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5803290","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5803290","identity":"rs-5803290","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}