Abstract
Objective: To analyze chiropractic utilization on National Football League (NFL) medical teams and the role played by chiropractors. Design: Postal survey of head athletic trainers of the 36 teams. Survey questions were developed from responses to a questionnaire submitted to a pilot group of 30 sport chiropractors and a panel of 20 postdoctoral faculty of the sport chiropractic program of the American Chiropractic Board of Sport Physicians, as well as a representative from the University of South Alabama. Results: Twenty-two of 36 questionnaires were returned for a return rate of 66%. Of the trainers who did respond, 45% have personally been treated by a chiropractor, and 55% have not. Seventy-seven percent of the trainers have referred to a chiropractor for evaluation or treatment, and 23% have not. Thirty-one percent of NFL teams use a chiropractor in an official capacity on their staffs, and 69% do not. When asked to identify conditions appropriate for referral to a chiropractor, the respondents identified low back pain (61%), “stingers” and “burners” usually associated with neck injury (31%), headaches (8%), asthma or other visceral disorders (0%). All respondents (100%) agree that some players use chiropractic care without referral from team medical staff. Conclusion: There is significant chiropractic participation in US professional football. Certified athletic trainers see a role for the sport chiropractor in the NFL, primarily as a spinal specialist treating low back and other musculoskeletal injuries. A substantial majority of NFL trainers have developed cooperative relationships with chiropractors, with 77% having referred a player to a chiropractor. Thirty-one percent of NFL teams have a chiropractor officially on staff, and an additional 12% of teams refer players to chiropractors but do not directly retain these chiropractors. (J Manipulative Physiol Ther 2002;25:E2)
Keywords
Introduction
Because professional sports are highly competitive and thus intensely pragmatic, they provide an arena in which new techniques can potentially move quickly toward widespread acceptance once their efficacy is established. At each of the Olympic Games since 1980, an official chiropractic physician has been assigned to the United States team. A chiropractic physician training program has been in place since 1986 at the United States Olympic Training Center in Colorado Springs, Colo. Chiropractors have also served in official capacities at the Asian Games and Pan American Games. The surge of interest in sports and fitness in recent years,
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at both the amateur and professional levels and among both men and women, has produced a corresponding interest among athletes in chiropractic treatment.Basic chiropractic training places central emphasis on treatment of musculoskeletal injuries, and sport chiropractors have additional training in this area.
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There has been a significant increase in the demand and support for chiropractic care by athletes and their coaches. Joe Montana, Martina Navratilova, and Charles Barkley are among the high-profile professional athletes treated by doctors of chiropractic during their careers.4
Sports account for 10% to 15% of all severe spinal injuries. The majority of catastrophic injuries in American football are head and neck injuries.
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Although football has received much media attention in this regard, recreational water sports have been identified as the cause of most sports-related severe spinal injuries., 8
The incidence of back pain in professional athletes is reportedly as high as 75% per year.
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This is especially true in football, a sport in which considerable time in the off-season is devoted to weight training. Excessive axial loading of the spine has been suggested as one cause of the high incidence of back pain in this group.8
During one year, 50% of the down linemen at a Division-I university sought medical attention for low back pain.8
Other studies report that up to 27% of college football players develop lumbar spine problems during their careers.9
Pitts and Popovich studied injuries of NFL players between the 1960s and 1990s and found an increasing incidence of NFL career-terminating injuries, with 46% of retiring players reporting injuries as the reason for their retirement (unpublished manuscripts, Ball State University, 1990, 1994).Morley
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examined the effectiveness of manipulation of the spine and/or lower extremities in the treatment of chronically injured athletes and found that restoration of joint mobility and reduction of trigger points resulted in a noticeable improvement in ability to perform particular athletic events and a significant reduction in pain. Both manipulation and trigger point therapy are central aspects of chiropractic treatment. There is substantial documentation for the efficacy of spinal manipulation in the treatment of low back pain11
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and other musculoskeletal disorders.16
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Our objective was to analyze chiropractic use and the role played by chiropractors on NFL medical teams.
Methods
A survey questionnaire was developed that used 10 demographic questions relating to training experience and 30 questions addressing the frequency and nature of referral of players to sport chiropractors and the modalities of treatment used. The college reading level used to enhance clarity and understanding of the questions was advised by a professor of English, reading, and business management at the University of South Alabama. Questions were developed from survey questions submitted to a pilot group of 30 sport chiropractors and a panel of 20 postdoctoral faculty of the sport chiropractic program,
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as well as the aforementioned professor.Subjects
Participants were the head athletic trainers of the 36 National Football League teams. The subjects were all men, and each had at least 17 years of experience and had served in this position a minimum of 1 year with their present team.
Reliability and validity
Because the questionnaire used in this study was an original instrument developed by one of us, reliability and validity had to be established. The instrument was submitted to a pilot group of 30 sport chiropractors for review to ascertain whether the questions were pertinent to determining to what extent and under what circumstances sport chiropractors are used in the National Football League. Results of the pilot survey questionnaire were then submitted to a panel of 20 educators on the faculty of the Chiropractic Colleges Sports Injury Program. The panel was asked to suggest appropriate changes. The revised questionnaire was then resubmitted for final revisions to a third panel of 5 chiropractors who teach advanced programs in sport chiropractic. The questionnaire was then finalized by the researcher and sent to the head certified athletic trainer target study group (N = 36).
The 2 panels of chiropractors with advanced certification in sport chiropractic (who were not employed by the National Football League) were suggested by the sitting chair of the Department of Postgraduate Education at Parker College of Chiropractic in Dallas, Tex, and by a consultant to members of the NFL Players Association in Washington, DC.
Reliability of the instrument was established by having the chiropractic physician group complete the questionnaire a second time, 1 month later. The results of these 2 surveys are in a 1:1 correlation coefficient of.88.The results received from both groups were identical within the cells of agreement or disagreement. Reliability of this instrument was further established by submission to members of an expert panel, who were asked whether the instrument precisely depicted areas of chiropractic concern in relation to sports management. All 20 members of the expert panel agreed the instrument accomplished that purpose, as did all 5 members of the final review panel of educators.
Group comparisons
The Pearson product moment correlation coefficient was used to measure the strength of the relationship among the studied groups.
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By using the grand means (sum of means), all studied groups were compared with each other. The.05 level for statistical significance was used throughout.Procedures
Questionnaires were mailed to the head athletic trainers of all 36 teams in the NFL, coded for comparability, and accompanied by a stamped return envelope. Twenty-two questionnaires were returned (66%). In Educational Research Competencies for Analysis and Application,
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Gay states that when questionnaires are mailed to a sample population, the return should be close to 50%, and additional follow-ups should add approximately 10% to that figure. According to Gay's figures, the 66% return in this study provides a viable sample. Nonrespondents were sent reminder questionnaires 2 weeks after the initial letter. Faxed reminders were sent 2 weeks after the reminder letters, and telephone reminders followed 1 week after the faxed reminders. On telephone follow-up, 5 additional trainers reported they did not have time to devote to responding to the written questionnaire but were willing to be interviewed by telephone. Two of these stated that they did not want their name or the team name used for fear of possible reprimand by the team physician. The telephone questionnaire responses were kept separate from the written responses.Results
Highest degree of education completed and major area of emphasis All trainers (100%) have at least a bachelor's degree, 52% have a master's degree, and 79% majored in health and physical education.
Work as an athletic trainer before joining the NFL A majority of trainers (82%) worked as trainers with college teams before entering the NFL, but 18% did not.
Have trainers been personally treated by chiropractors? Forty-five percent of trainers have been treated by a chiropractor, and 55% have not.
Have trainers worked professionally with a chiropractor? Seventy-one percent of respondents have worked professionally with a chiropractor, and 29% have not.
Is the chief of the team's medical staff a medical doctor, and if so, in what specialty? One hundred percent of NFL medical staffs are headed by a medical doctor; more than half specialize in orthopedics.
Who decides the makeup of the team's medical staff? Seventy-four percent of trainers agree that this decision is made by the team physician and management; 26% disagree.
Does the team use a chiropractor in an official capacity as part of its staff? Thirty-one percent of NFL teams use chiropractors in an official capacity as part of their staffs; 69% do not.
Is low back injury common in the NFL? Thirty-six percent of trainers strongly agree, 55% agree, and 9% disagree.
What is the probable percentage of low back injury on the team? Twenty-seven percent of trainers report an incidence of 5% to 10%, 37% report an incidence of 16% to 20%, and 9% report an incidence of up to 25%. None report an incidence of over 25%.
Does low back pain result in early retirement of some players? Five percent of trainers strongly agree, 59% agree, 27% disagree, and 9% have no opinion.
What kinds of problems are appropriate for chiropractors to treat? Low back pain (61%) “stingers” and “burners” (usually associated with neck injury) (31%), headaches (8%), asthma or other visceral disorders (0%).
Have you ever referred a player to a chiropractor for evaluation or treatment? Seventy-seven percent of the trainers have referred to a chiropractor for evaluation or treatment; 23% have not.
For what condition was this referral made? Seventy-three percent report referrals to chiropractors for “low back injury,” and 27% report referrals for “musculoskeletal conditions.”
Do some players use chiropractic without referral from the medical staff? One hundred percent of trainers agree that some players use chiropractic care without referral from team medical staff.
Use of mobilization techniques by trainer? All (100%) of the NFL trainers report mobilization as one of their procedures for injury care.
Use of manipulation techniques by trainer? Eighty-two percent of the trainers report the use of manipulation techniques for injury care.
Should trainers refer players with suspected spinal subluxations to chiropractors? Five percent of trainers strongly agree, 48% agree, 24% disagree, and 19% have no opinion.
Are chiropractors adequately trained in the diagnosis of spinal problems? Forty-five percent of trainers agree that the chiropractor's training is adequate, 14% state that the training is inadequate, and 41% offer no opinion.
Should chiropractors have postdoctoral sports-injury training before they provide services for NFL players? Thirty-two percent of trainers strongly agree, 36% agree, none disagree, and 32% offer no opinion.
Is there a role for the doctor of chiropractic in the NFL? Eighty-one percent agree that there is a role for the chiropractor in the NFL, 5% strongly agree, 14% have no opinion, and none disagree.
Is the role of the sport chiropractor different from that of the team physician? All (100%) of the trainers see these roles as different from each other.
Do you refer most low back injuries to an orthopedist, physical therapist, or chiropractor? Eighty-one percent refer to an orthopedist, 36% refer to a chiropractor, and 5% refer to a physical therapist. (The total is more than 100% because some trainers refer a majority of cases to more than one practitioner.)
Method of reimbursement for services provided by a chiropractor for the team and player? Eighteen percent report reimbursement by team insurance, 9% by team management, 59% by the individual players, and 14% by “other.”
For teams that do not employ a sport chiropractor on staff, has your team considered doing so? Sixty percent of trainers on teams that do not employ a sport chiropractor report that their teams have considered employing one, 30% report that their teams have not, and 10% have no opinion.
Reasons that would justify treatment of an athlete by a sport chiropractor? Low back pain (32%), spinal manipulation (28%), neck pain (22%), and musculoskeletal injury (8%).
Discussion
There is significant chiropractic participation in professional football in the United States. Certified athletic trainers see a role for the sport chiropractor in the NFL, primarily as a spinal specialist treating low back and other musculoskeletal injuries. A substantial majority of NFL trainers have developed cooperative relationships with chiropractors, with 77% having referred a player to a DC. In addition, all trainers report that some of their teams' players seek chiropractic services on their own without official referral. At present, 31% of NFL teams have a DC officially on staff, whereas an additional 12% of teams refer players to chiropractors but do not directly retain these DCs.
Conclusion
Trainers agree that chiropractors are adequately trained and specialize in the use of spinal manipulation. They feel that chiropractors should have postgraduate education in sports-injury care and management before working in the NFL and that DCs should work under the direction of the team physician and trainers when on the medical staff of an NFL team. Trainers display a generally positive attitude toward chiropractic inclusion on their teams' medical staffs, and 5 trainers praised at great length the sport chiropractors with whom they have worked. However, 2 trainers asked that their names and the names of their teams not be placed on the written survey, for fear of reprimand by the teams' medical physicians. This indicates residual antipathy toward chiropractors on the part of some team medical physicians. (Before 1980, the American Medical Association forbade its members to refer patients to chiropractors or to receive referrals from them.) Hopefully, this antipathy will fade as chiropractic moves further into the professional sports health care mainstream.
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Article info
Publication history
Received:
November 9,
2000
Footnotes
*Submit reprint requests to: John L. Stump, DC, 401 N Section St, Fairhope, AL 36532, USA.
Identification
Copyright
© 2002 JMPT. Published by Elsevier Inc. All rights reserved.
