Advertisement

Utilization of Chiropractic Care at the World Games 2013

Published:November 09, 2016DOI:https://doi.org/10.1016/j.jmpt.2016.09.005

      Abstract

      Objective

      The purpose of this study was to describe chiropractic care use at the World Games 2013.

      Methods

      In this retrospective study, we reviewed treatment charts of athletes and non-athletes who sought chiropractic care at The World Games in Cali, Colombia, from July 25 to August 4, 2013. Doctors of chiropractic of the International Federation of Sports Chiropractic provided care. Chart notes included body region treated, treatment modality, and pretreatment and posttreatment pain ratings.

      Results

      Of the participants, 537 of 2964 accredited athletes and 403 of 4131 accredited non-athletes sought chiropractic treatment; these represent utilization rates of 18.1% for athletes and 9.8% for non-athletes. A total of 1463 treatments were recorded for athletes (n = 897) and non-athletes (n = 566). The athletes who were treated represented 28 of 33 sports and 68 of 93 countries that were present at the games. Among athletes, the thoracic spine was the most frequent area of treatment (57.2%), followed by the lumbar spine (48.7%) and the cervical spine (38.9%). Myotherapy was the most frequently used treatment method (80.9%), followed by chiropractic manipulation (78.5%), taping (38.0%), and mobilization (24.6%). Reports of acute injury were higher among athletes (45.4%) compared with non-athletes (23.8%). Reported pain was reduced after treatment (P < .001), and 86.9% patients reported immediate improvement after receiving chiropractic treatment.

      Conclusions

      The majority of people seeking chiropractic care at an international sporting competition were athletes. For those seeking care, the injury rate was higher among athletes than among non-athletes. The majority of patients receiving chiropractic care reported improvement after receiving care.

      Key Indexing Terms

      Introduction

      Injury surveillance and reporting systems used at the Olympic and Paralympic Games analyze the standard reporting form used by medical professionals, the types of injuries sustained by athletes, and the frequency of injuries to each body region.
      • Engebretsen L
      • Steffen K
      • Alonso JM
      • et al.
      Sports injuries and illnesses during the Winter Olympic Games 2010.
      • Grant M-E
      • Steffen K
      • Glasgow P
      • Phillips N
      • Booth L
      • Galligan M
      The role of sports physiotherapy at the London 2012 Olympic Games.
      • Vanhegan IS
      • Palmer-Green D
      • Soligard T
      • et al.
      The London 2012 Summer Olympic Games: an analysis of usage of the Olympic Village “Polyclinic” by competing athletes.
      • Derman W
      • Schwellnus M
      • Jordaan E
      • et al.
      Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff.
      • Junge A
      • Engebretsen L
      • Alonso JM
      • et al.
      Injury surveillance in multi-sport events: the International Olympic Committee approach.
      However, research on patterns in competitions other than the Olympics and on approaches other than Western medicine, such as the use of chiropractic care, is still lacking.
      Chiropractic is considered an important form of complementary and alternative medicine.
      • Mącznik AK
      • Schneiders AG
      • Sullivan SJ
      • Athens J
      What “CAM” we learn about the level of evidence from 60 years of research into manipulative and body-based therapies in sports and exercise medicine?.
      • Xue CCL
      • Zhang AL
      • Lin V
      • Myers R
      • Polus B
      • Story DF
      Acupuncture, chiropractic and osteopathy use in Australia: a national population survey.
      • Ni H
      • Simile C
      • Hardy AM
      Utilization of complementary and alternative medicine by United States adults: results from the 1999 national health interview survey.
      Early reports in 1980 described use of chiropractic care in only 4% of the population, but this figure has grown, and the United States and Canada have the highest utilization rates.
      • Hurwitz EL
      Epidemiology: spinal manipulation utilization.
      A recent report suggested that the chiropractic utilization rate in the preceding 12 months is near 14% in the United States. Those seeking alternative care for sprains and muscle strains tend to seek chiropractic care, and there is growing evidence that chiropractic care is an effective treatment for back pain.
      • Astin JA
      Why patients use alternative medicine: results of a national study.
      • Goertz CM
      • Long CR
      • Hondras M
      • et al.
      Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.
      • Rubinstein SM
      • van Middelkoop M
      • Assendelft WJJ
      • de Boer MR
      • van Tulder MW
      Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review.
      • Koes BS
      • Assendelft WJ
      • van der Heijden GJ
      • Bouter LM
      • Knipschild PG
      Spinal manipulation and mobilization for back and neck pain: a blinded review.
      • Meeker WC
      A meta-analysis of clinical trials of spinal manipulation.
      • Meade TW
      • Dyer S
      • Browne W
      • Frank AO
      Randomised comparison of chiropractic and outpatient management for low back pain: results from extended follow up.
      A large-scale study of 1.7 million people demonstrated that access to insurance coverage for chiropractic care was associated with reduced total health care expenditures, reduced low back surgery, and reduced health care costs for back pain episodes.
      • Legorreta AP
      • Metz D
      • Nelson CF
      • Ray S
      • Chernicoff HO
      • DiNubile NA
      Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.
      However, less is known about the impact of chiropractic care for athletes. More research is needed on sports injuries among athletes and coaches and on sports medical professionals.
      • Finch CF
      Getting sports injury prevention on to public health agendas—addressing the shortfalls in current information sources.
      Chiropractic care has been provided at various national and international sporting events, and preliminary studies on these events indicate that chiropractic care is an accepted, well-used treatment option for athletes and support staff.
      • Kazemi M
      • Shearer H
      Chiropractic utilization in Taekwondo athletes.
      • Stump JL
      • Redwood D
      The use and role of sport chiropractors in the National Football League: a short report.
      However, further research is needed to establish the replicability and generalizability of these patterns of results.
      • Nook B
      • Nook D
      Demographics of athletes and support personnel who used chiropractic physicians at the 6th All Africa Games.
      • Nook DD
      • Nook BC
      A report of the 2009 World Games injury surveillance of individuals who voluntarily used the International Federation of Sports Chiropractic delegation.
      Previous reports have not investigated whether the rates of injury and commitment to follow-up care differ between athletes and non-athletes.
      The purposes of this study were to describe
      • Engebretsen L
      • Steffen K
      • Alonso JM
      • et al.
      Sports injuries and illnesses during the Winter Olympic Games 2010.
      patient demographics (athlete vs non-athlete status, nationality, and sport),
      • Grant M-E
      • Steffen K
      • Glasgow P
      • Phillips N
      • Booth L
      • Galligan M
      The role of sports physiotherapy at the London 2012 Olympic Games.
      patterns of chiropractic treatment, and
      • Vanhegan IS
      • Palmer-Green D
      • Soligard T
      • et al.
      The London 2012 Summer Olympic Games: an analysis of usage of the Olympic Village “Polyclinic” by competing athletes.
      the reported level of pain before and after chiropractic treatment.

      Methods

      This retrospective descriptive study evaluated chiropractic treatment forms at an international sporting event. The International World Games Association (IWGA) contracted with Fédération Internationale de Chiropratique du Sport (FICS) to provide free chiropractic care to any persons accredited at their events. The Cali Local Organizing Committee executed this agreement for The World Games 2013 (TWG2013) by accrediting 40 doctors of chiropractic (DCs) and 6 researchers. The treatment team then provided chiropractic care to athletes and volunteers at the event. The research team reviewed treatment characteristics.
      Patients voluntarily sought care over the 10-day event occurring from July 25 through August 4, 2013. Doctors of chiropractic completed a paper treatment form each time a patient sought care. This form included demographic characteristics, chiropractic treatments performed (including the type of treatment and body region treated), and patient pretreatment and posttreatment visual analog scale (VAS) pain scores. Data from these forms were entered into a Microsoft Excel (Redmond, Washington) spreadsheet at the end of each day for analysis.

      Participants

      Participants were limited to TWG2013 accredited athletes and support personnel (non-athletes). The FICS delegation recorded a total of 1583 treatments. One-hundred twenty (7.6%) treatment forms were excluded because of an incomplete treatment record (n = 81; 5.1%) or because the patient was aged <18 years (n = 39; 2.5%). Our final analysis included 1463 treatment records representing 940 individuals.

      Research Protocol

      Patients who sought care received an information letter that described the aims and methods of the study. If patients expressed interest in participating, they read and signed a consent form before treatment. Participants were assigned an identification number to protect their confidentiality while still allowing the delegation to identify those who returned for follow-up care. The Murdoch University Human Research Ethics Committee approved all research methods for this study (ethics number 2013/017).
      On each form, treating DCs recorded the patient’s age, sex, and the country they represented; whether it was the participant’s first visit or a follow-up visit; and whether the complaint was acute, chronic, or a combination of acute and chronic conditions. Acute conditions were defined as conditions of immediate onset, and chronic conditions were identified as those lasting >3 months (in concurrence with O’Halloran’s definition
      • O’Halloran J
      • Miller GC
      • Britt H
      Defining chronic conditions for primary care with ICPC-2.
      ). The accredited sport role for athletes and the accredited role for non-athletes (ie, whether they were volunteers, coaches, IWGA staff members, or medical staff members) were recorded. A physical examination was performed to determine the treatment method necessary for that patient. The DCs selected which body regions required treatment from a list of 17 body regions on the treatment form. For treatment type, the DCs indicated whether they applied manipulation (high-velocity low-amplitude), mobilization (passive movement of a joint within its physiological range of motion), myotherapy, or taping. Myotherapy included the use of effleurage, petrissage, tapotement, cross-friction massage, and percussion. Taping was done by applying rigid, elastic, and/or functional tape to the affected joints and muscles.
      Treatment forms included 2 VASs to measure participants’ pain levels.
      • Hawker G
      • Mian S
      • Kendzerska T
      • French M
      Measures of adult pain.
      • Bijur P
      • Silver W
      • Gallagher E
      Reliability of the visual analog scale for measurement of acute pain.
      The VAS line was an unmarked line that allowed patients to freely indicate their pain level at any point along a 100-mm line.
      • Johnson C
      Measuring pain. Visual Analog Scale versus numeric pain scale: what is the difference?.
      The pretreatment VAS was located on the front of the form and was completed by the patient before any treatment was administered by the DC. The posttreatment VAS line was located on the back of the form and was completed by the patient immediately after treatment. Patients were allowed to complete VAS ratings without being observed by the DC. This method allowed participants to give ratings that were not biased by their previous rating or by the presence of the DC. Patients marked the point that corresponded to their pain level on a 100-mm VAS line, ranging from “no pain” to “severe pain.” These marks were then measured by using a ruler to quantify the amount of pain each mark represented on a scale from 0 (no pain) to 10 (severe pain).

      Statistical Methods

      Data from the treatment forms were entered into Microsoft Excel spreadsheets at the end of each day. We analyzed patterns of utilization, patient demographics, and treatment characteristics by using basic calculations of frequencies, utilization rates, and means in Excel. Swiss Timing provided records of the total number of individuals who had been accredited for TWG2013 from each country and their sport or non-athletic role. Utilization rate was defined as the proportion of individuals who were treated out of the total number of individuals who were accredited for a sport, country, or non-athletic role. We also computed the percentage of treatments out of the total number of treatments by sport or country (ie, 897 treatments for athletes or 566 treatments for non-athletes).
      We used SPSS version 20 (SPSS Inc., Chicago, Illinois) to conduct statistical analyses exploring 3 questions of interest. First, we used the χ2 test to assess whether the proportion of patients who returned for follow-up visits differed between athletes and non-athletes. Second, we used the χ2 test to determine whether the prevalence of acute conditions differed between athletes and non-athletes. Because we were interested in the prevalence of acute injuries, new patient forms were split dichotomously as involving or not involving an acute condition. The small number of participants who presented with both acute and chronic conditions (n = 59; 6.3%) were coded as having acute conditions for the purposes of the χ2 test. Third, we used a paired-samples t test to assess whether pretreatment VAS pain ratings differed significantly from posttreatment pain ratings across all treatments.

      Results

      Utilization of Voluntary Chiropractic Care

      Patients who requested chiropractic care completed a consent form and agreed to participate in this study. Of the 1463 treatment forms that met the inclusion criteria, a total of 897 (61%) were for athletes and 566 (39%) were for non-athletes. A total of 940 individuals sought care, with 523 treatments (36%) for follow-up care (Table 1). Of the 2964 accredited athletes, 537 sought treatment; 403 of 4131 accredited non-athletes sought treatment. Utilization rates were 18% and 10% for athletes and non-athletes, respectively.
      Table 1Patient Demographics
      RoleAge, Mean (SD)Gender, Males/Females
      Athletes27.7 (6.8)312/225
      Non-athletes34.9 (14.0)257/146
       Volunteers24.8 (11.7)129/102
       IWGA Staff43.6 (11.8)81/27
       Coaches48.4 (9.8)33/7
       Medical Staff31.2 (14.0)14/10
      IWGA, International World Games Association.

      Athlete Utilization by Country

      Athletes seeking treatment were from 68 (73%) of the 93 countries present at TWG2013. Utilization rates for athletes (ie, the number of a country’s athletes who sought treatment divided by total number of accredited athletes for that country and then multiplied by 100) varied across countries (Table 2). Several countries (ie, Jamaica, Mauritius, Dominican Republic, and Uruguay) had utilization rates over 50%; however, these countries had small numbers of accredited athletes (ie, fewer than 20) attending the games. Of the countries that had at least 20 athletes attending the games, the highest utilization rates were found among athletes from the United States (42%), Brazil (36%), Sweden (33%), Norway (32%), and Colombia (31%). Although 25 countries had utilization rates of 0%, these countries represented only 28% of the 63 countries present at the game. We explored which countries used the greatest proportion of treatments out of all treatments provided by the delegation. Patterns from this analysis differ slightly: Athletes from the United States received the largest proportion of treatments (15%), followed by those from Colombia (10%) and Italy (7%).
      Table 2Athlete Utilization of Chiropractic Care by Country
      CountryNo. Accredited AthletesFirst-Visit TreatmentsFollow-Up TreatmentsTotal Treatments (first visits/accredited)% Utilization Treatments% of Total (N = 897)
      Algeria10000.00.0
      Argentina6672910.61.0
      Aruba17731041.21.1
      Australia8317112820.53.1
      Austria43821018.61.1
      Azerbaijan520240.00.2
      Belarus141017.10.1
      Belgium582023.50.2
      Bermuda523540.00.6
      Bolivia50000.00.0
      Brazil7728134136.44.6
      Bulgaria50000.00.0
      Canada912082822.03.1
      Chile361091927.82.1
      China1191241610.11.8
      Chinese Taipei6464109.41.1
      Colombia20564238731.29.7
      Costa Rica5291140.01.2
      Croatia181125.60.2
      Cuba201235.00.3
      Czech Republic70771410.01.6
      Denmark16881650.01.8
      Dominican Republic6461066.71.1
      Ecuador151016.70.1
      Egypt1760635.30.7
      El Salvador210150.00.1
      Estonia70000.00.0
      Ethiopia10000.00.0
      Finland1044840.00.9
      France15174114.61.2
      Germany14315102510.52.8
      Great Britain10479166.71.8
      Greece212350.00.3
      Guatemala22551022.71.1
      Guyana10000.00.0
      Hungary582133.50.3
      India1130327.30.3
      Indonesia80000.00.0
      Iran17661235.31.3
      Ireland2050525.00.6
      Israel1123518.20.6
      Italy9626396527.17.3
      Jamaica1101100.00.1
      Japan761001013.21.1
      Jordan10000.00.0
      Kazakhstan50000.00.0
      Kuwait10000.00.0
      Latvia33861424.21.6
      Lithuania80000.00.0
      Luxembourg20000.00.0
      Malaysia1232525.00.6
      Malta311233.30.2
      Mauritius1101100.00.1
      Mexico361041427.81.6
      Moldova20000.00.0
      Monaco20000.00.0
      Mongolia180000.00.0
      Montenegro30000.00.0
      Morocco30000.00.0
      Namibia10000.00.0
      Netherlands841071711.91.9
      New Zealand2370730.40.8
      Nicaragua20000.00.0
      Norway28971632.11.8
      Pakistan10000.00.0
      Peru420250.00.2
      Philippines520240.00.2
      Poland351011128.61.2
      Portugal383037.90.3
      Puerto Rico410125.00.1
      Qatar90000.00.0
      Romania110000.00.0
      Russia11464104.21.1
      Senegal10000.00.0
      Serbia40000.00.0
      Singapore20000.00.0
      Slovakia1620212.50.2
      Slovenia1221316.70.3
      South Africa414269.80.7
      South Korea391081825.62.0
      Spain372135.40.3
      Sweden5217163332.73.7
      Switzerland721131415.31.6
      Thailand111019.10.1
      Trinidad and Tobago60000.00.0
      Tunisia844850.00.9
      Turkey844850.00.9
      Ukraine893143.40.5
      United Arab Emirates30000.00.0
      United States132568113742.415.3
      Uruguay1480857.10.9
      Venezuela872773431.03.8
      Vietnam922422.20.5
      Total296453736089718.1100.0

      Non-athlete Utilization by Role

      Analyses of non-athlete utilization rates (Table 3) revealed that a large proportion of accredited medical staff (30%) and IWGA staff (12%) sought treatment. However, the patients who received the greatest number of treatments (athlete or non-athlete) were native Colombian volunteers (307 treatments; 54% of non-athlete treatments and 21% of all treatments).
      Table 3Non-athlete Utilization of Chiropractic Care by Role
      RoleNo. Accredited Non-athletesFirst-Visit TreatmentsFollow-Up TreatmentsTotal Treatments% Utilization (first visits/accredited)% of Non-athlete Treatments
      Volunteers2493231763079.3%54.2%
      IWGA staff8821085316112.2%28.5%
      Coaches6764017575.9%10.1%
      Medical staff8024174130.0%7.2%
      IWGA, International World Games Association.

      Athlete Utilization by Sport

      Athletes from 28 (85%) of 33 sports were present at TWG2013. Athletes’ utilization rates by sport (ie, the number of athletes per sport who sought treatment divided by the total number of accredited athletes for that sport, multiplied by 100) are displayed graphically in Figure 1A . The sports with the largest utilization rates were bowling (48%), water skiing (42%), fistball (41%), and wushu (41%). The sports with the lowest utilization rates were duathlon (1%), korfball (5%), gymnastics (6%), and climbing (6%). Athletes of 3 sports—air sports, boules, and orienteering—did not seek chiropractic care. The pattern of results shifted when we computed the percentage of total treatments per each sport (Fig 1B). The sports with the largest proportion of total treatments were flying disk (11%), roller inline hockey (8%), speed roller skating (8%), and water skiing (8%). The sports with the lowest proportion of total treatments were climbing (6%), gymnastics (6%), korfball (5%), and duathlon (1%).
      Fig 1
      Fig 1Athlete use of chiropractic care by sport. Each sport’s utilization rate (percentage of accredited athletes who sought care) (A) and percentage of treatments for each sport of the total number of treatments (B).

      Follow-Up Care for Athletes and Non-athletes

      A greater proportion of athletes (44%) compared with non-athletes (31.5%) returned for follow-up care (χ2 [1, n = 940] = 15.02; P < .001; Fig 2A ).
      Fig 2
      Fig 2Percentage of athletes and non-athletes who did (dark) or did not (light) return for follow-up care (A) and the percentage of new patient athletes and non-athletes who presented with both chronic and acute (darkest), only acute (dark), or only chronic (lightest) conditions (B).

      Prevalence of Acute and Chronic Conditions for Athletes and Non-athletes

      There were differences between athletes and non-athletes in the prevalence of acute and chronic conditions (Fig 2B). Of athletes presenting for treatment, 201 (37%) presented with acute conditions, 293 (55%) presented with chronic conditions, and 43 (8%) presented with both acute and chronic conditions. However, only 80 (20%) non-athletes presented with acute conditions, 307 (61%) presented with chronic conditions, and 16 (4%) presented with both acute and chronic conditions. When coded dichotomously, the prevalence of acute conditions was greater for athletes (45%) than for non-athletes (23.8%, χ2 [1, n = 940] = 46.59; P < .001). The significance did not change if participants who had both acute and chronic conditions were coded as having chronic rather than acute conditions (χ2 [1, n = 940] = 33.95; P < .001).

      Athlete Treatments by Body Region

      The proportions of treatments for each body region in athletes are shown in Figure 3A . The most frequently treated regions were the thoracic spine (513 treatments; 57%), lumbar spine (437 treatments; 49%), cervical spine (349 treatments; 39%), and sacroiliac joint (209 treatments; 23%). For extremities, the most frequently treated regions were the shoulder (159 treatments; 18%) and the thigh (121 treatments; 14%). We also tabulated the number of treatments applied to each body region for each sport (Table 4).
      Fig 3
      Fig 3Percentage of athlete visits that involved treatment of each body region (A) and percentage of total treatments that used each treatment method (B).
      Table 4Number of Athlete Treatments for Each Region, Split by Sport
      SportThoracicLumbarCervicalSacroiliacShoulderThighHipKneeCalfAnkleElbowHeadWristFootHandFingerToes
      Bowling91316810548352104101
      Water skiing4855431931173595202131
      Fistball252910310347031102010
      Wushu202181696612664022101
      Sumo301222109151361043201000
      Speed roller skating27231316315114840241101
      Flying disk36522033114311101529128781
      Artistic roller skating97193305320012110
      Inline roller hockey4327211516101316950144403
      Powerlifting27181275633220112100
      Jiu-Jitsu261319512151127010110
      Canoe polo24618217123327011100
      Softball23172421314207754204011
      Squash131510115002023500000
      Billiards23131920622100200000
      Field archery2072157153111301000
      Rugby17171230321220111000
      Tug of war212316106102002831101
      Karate310421001000040110
      Beach handball1416572418000102100
      Racquetball43102000001010000
      Finswimming710462000000000000
      Lifesaving106528000201000001
      Dance sport1261121512110020000
      Climbing55510420110110000
      Gymnastics1113784250111100000
      Korfball50250112010010000
      Duathlon10000000000000000
      Total513437349209159121110109767344433938221611

      Treatment Method Across All Patients

      The most frequently used treatment method across all patients (combining athletes and non-athletes) was myotherapy (1183 treatments; 81%), followed by manipulation (1148 treatments; 79%), taping (556 treatments; 38%), and mobilization (360 treatments; 25%; Fig 3B). Patterns of treatment type were similar for athletes and non-athletes, although non-athletes received a slightly larger proportion of treatments by manipulation. Athletes received, in descending order of frequency, myotherapy (730 treatments; 81%), manipulation (687 treatments; 77%), taping (353 treatments; 39%), and mobilization (234 treatments; 26%). Non-athletes received, in descending order of frequency, manipulation (461 treatments; 82%), myotherapy (453 treatments; 80%), taping (203 treatments; 36%), and mobilization (126 treatments; 22%).

      Treatment Reduction of Reported Pain

      Reported pain across all treatments was statistically significant (t [1462] = 51.75; P < .001). The Cohen’s d for this difference was 1.39 (ie, a large effect size).
      • Cohen J
      Statistical power analysis for the behavioral sciences.
      Furthermore, 1271 patients (87%) reported experiencing an immediate reduction in pain after treatment. See Table 5 for further details on pretreatment and posttreatment pain ratings for athletes and non-athletes.
      Table 5Details of VAS Ratings of Pain for Athletes, Non-athletes and All Patients
      VariableAthletesNon-athletesTotal
      Mean pretreatment VAS4.2 (2.3)4.7 (2.3)4.4 (2.3)
      Mean posttreatment VAS1.7 (1.7)1.6 (1.5)1.7 (1.6)
      Mean change in VAS–2.5 (2.0)–3.1 (2.1)–2.8 (2.0)
      Number of treatments resulting in immediate pain reduction7585131271
      Percentage of treatments resulting in immediate pain reduction84.5%90.6%86.9%
      Note: With the visual analog scale (VAS) for pain, higher numbers indicate greater pain. Numbers in parentheses represent standard deviation.

      Discussion

      “Empowering athletes to maximal performance… naturally” is the mission statement of FICS,
      • The International Federation of Sports Chiropractic
      which is the only international chiropractic federation recognized by SportAccord. SportAccord is the overarching world governing body that unites and supports all recognized international sports federations while preserving their autonomy.
      We found in the present study that use of chiropractic care at TWG2013 was similar to that at the World Games 2009
      • Nook DD
      • Nook BC
      A report of the 2009 World Games injury surveillance of individuals who voluntarily used the International Federation of Sports Chiropractic delegation.
      and higher than typical rates of care use in the general population.
      • Peregoy JA
      • Clarke TC
      • Jones LI
      • Stussman BJ
      • Nahin RL
      Regional variation in use of complementary health approaches by U.S. adults.
      Athletes were more likely than non-athletes to experience acute injury and seek follow-up treatment. The most commonly used treatment strategies were myotherapy and manipulation, and the most frequently treated region was the spine. Finally, we found that chiropractic treatment had a large effect on reported pain.
      Athlete utilization rates suggested that athletes from countries where chiropractic is recognized in health care or from the host nation are most likely to seek care. We found that athletes who used chiropractic services represented the United States, Colombia, and Italy. Chiropractic is an accepted form of manual therapy in the United States. There are 7943 registered DCs for the 316.15 million people in the United States and 196 registered DCs for the 61.32 million people in Italy. However, in Colombia, only 6 registered DCs serve a population of 47.07 million people. The Chiropractic Association of Colombia, established in 2010, is relatively young. Hence, the substantial use by individuals from Colombia, even with its overall small number of local DCs, suggests that use by the host nation’s population (particularly by non-athletes) is elevated. Conversely, few athletes from countries with low numbers of practicing DCs sought chiropractic treatment at these games. Hence, providing chiropractic care at international sporting events may be a method of exposing local communities to the value of chiropractic treatment. These results are supported by findings from other research studies that reported positive relationships between the local availability of chiropractors and use of chiropractic care.
      • Shekelle PG
      • Brook RH
      A community-based study of the use of chiropractic services.
      • Whedon JM
      • Song Y
      • Davis MA
      • Lurie JD
      Use of chiropractic spinal manipulation in older adults is strongly correlated with supply.
      Although people from countries with more DCs per capita may be more likely to use care in this context, it is worth noting that the host country demonstrated an immense boost in use even with relatively a low concentration of DCs in its typical population. Hence, although the inclusion of DCs at sporting events is facilitated by athletes requesting chiropractic care,
      • Theberge N
      The integration of chiropractors into healthcare teams: a case study from sport medicine.
      these results suggest that increasing access to DCs may increase use. In other words, increasing chiropractic supply may drive increased demand for chiropractic care.
      Volunteers represented the largest proportion of non-athletes who received treatments. This result is similar to what was previously reported at the World Games 2009.
      • Nook DD
      • Nook BC
      A report of the 2009 World Games injury surveillance of individuals who voluntarily used the International Federation of Sports Chiropractic delegation.
      Volunteerism is a key part of all international multisport games, and there are various intrinsic benefits to volunteering. However, the addition of chiropractic service for volunteers is unique at the World Games, and the high utilization rates at TWG2013 suggested that this benefit was well accepted.
      Medical staff had the highest utilization rate among all non-athletes. This use may have been facilitated by the close proximity and integration of services provided by the medical staff and DCs at each venue and by the small number of medical staff compared with the large number of volunteers. This result may suggest that medical staff and DCs collaborated in supporting athletes, thus indicating that chiropractic services at multisport events should be integrated as closely as possible with all medical services to facilitate close collaboration with and understanding of each other’s services. This integration could lead to improvements in multidisciplinary medical care for athletes.
      The IWGA requested and provided appropriate treatment centers at each sporting venue for the FICS delegation to provide chiropractic services. Chiropractic treatment centers were in close proximity to the medical services area and the athlete warm-up area. This proximity provided good exposure and access to chiropractic care and helped support the other medical services at each venue. Bowling, water skiing, fistball, and wushu had the highest utilization rates among all sports, which is most likely because chiropractic care venues were in close proximity to the competition and athlete areas for these sports. The flying disk venue was also a particularly active treatment site during the 3 days of competition. Twenty-seven individuals sought care, with 70 recorded follow-up treatments. The 3 sports that did not have athletes who used chiropractic services—air sport, boules, and orienteering—did not have direct access to chiropractic care at their venues; however, these athletes were offered this service at a nearby venue. These patterns of use suggest that accessibility to chiropractic care at a sport’s venue facilitates athlete utilization of the service provided.
      • Shekelle PG
      • Brook RH
      A community-based study of the use of chiropractic services.
      • Whedon JM
      • Song Y
      • Davis MA
      • Lurie JD
      Use of chiropractic spinal manipulation in older adults is strongly correlated with supply.
      Thus, in addition to the treatment centers at each of the venues, a centralized treatment site may facilitate access to chiropractic treatment by all athletes and non-athletes across the Games. Likewise, expanding the duration of time that the team spends at the chiropractic treatment centers at the World Games (eg, by making these centers available before and after the Games) would further facilitate access to treatment and follow-up care.
      The reasons why athletes requested follow-up care more often compared with non-athletes can be explained. First, chiropractic care centers were placed within sporting venues. Hence, athletes may have had greater access to repeat care compared with non-athletes. Athletes frequently and consistently visited sporting complexes, whereas volunteers were stationed across the entire World Games venue in varying shift rotations. This potentially hindered volunteers seeking follow-up care. In addition, medical staff members (the non-athletes with the highest follow-up utilization rate) were most consistently stationed in close proximity to chiropractic services. The disparity in follow-up care use also could reflect differences between athletes and non-athletes in culture or training. Athletes may receive instruction from peers or coaches to seek follow-up care until injuries are healed, whereas non-athletes may not see the value in repeated care. Although either of these interpretations is possible, the motivations underlying these patterns of results should be studied more specifically in future research.
      Among those seeking chiropractic care, athletes had more acute injuries compared with non-athletes, possibly because athletes sustained acute sport injuries during competitions, whereas non-athletes did not.
      We found that the spine was the primary area of chiropractic treatment for patients seeking care. The reason may be the focus and training of DCs on the treatment of musculoskeletal issues of the spine. Sports DCs have extensive training on the relationship between the spine and the extremities in the biomechanics that produce optimal sport performance. The chiropractic focus on optimizing spinal function would naturally increase the frequency of spinal treatments.
      Identifying body regions that received treatments for each sport category provides helpful information in establishing key areas in which athletes and coaches can prevent injuries and optimize function. High demand placed on certain body regions is associated with more frequent injury in that area. In our study, the shoulder was the most commonly treated area other than the spine and was associated with sports such as canoe polo, roller inline hockey, softball, and jiu-jitsu. Flying disk was the only sport for which athletes required treatment to all body regions, which may suggest that flying disk involves elevated risk to all areas across the body.
      In our study, multiple treatment modalities were used by the DCs to treat athletes and non-athletes. Although it is encouraging to see that the DCs used multiple methodologies to treat patients, future research could extend this finding by exploring whether certain combinations of treatment methods are most effective at treating certain injury types.
      Similar to the findings from the World Games 2009,
      • Nook DD
      • Nook BC
      A report of the 2009 World Games injury surveillance of individuals who voluntarily used the International Federation of Sports Chiropractic delegation.
      we found that patients reported reduced pain after chiropractic treatment. There was also evidence that pain reduction was clinically significant in that chiropractic treatment reduced pain to a degree that affected patients’ health. We observed a very large effect size of chiropractic treatment on perceived pain, and overall average pain ratings changed from 4.4 to 1.7 on a scale of 0 to 10. This indicated that average pain ratings reduced from medium intensity to low intensity as a function of treatment.

      Limitations

      The chiropractic care centers were not equally distributed across different sports or nationalities, which may have affected athlete and non-athlete use of chiropractic care. Previous studies reported a positive relationship between the availability of chiropractors and the use of chiropractic care.
      • Shekelle PG
      • Brook RH
      A community-based study of the use of chiropractic services.
      • Whedon JM
      • Song Y
      • Davis MA
      • Lurie JD
      Use of chiropractic spinal manipulation in older adults is strongly correlated with supply.
      • Theberge N
      The integration of chiropractors into healthcare teams: a case study from sport medicine.
      Therefore, the specific patterns of use should be interpreted with potential availability bias in mind. A limited number of DCs and researchers were accredited at this large event, which may have inhibited participants’ access to care and influenced completeness of records. Paper-based data collection is prone to missing values (as evidenced by the records that had to be excluded) and may limit the time DCs spend with patients. Hence, the data presented here may be prone to subtle selection biases in that
      • Engebretsen L
      • Steffen K
      • Alonso JM
      • et al.
      Sports injuries and illnesses during the Winter Olympic Games 2010.
      we were only able to analyze treatment data from treatment forms that were fully characterized, and
      • Grant M-E
      • Steffen K
      • Glasgow P
      • Phillips N
      • Booth L
      • Galligan M
      The role of sports physiotherapy at the London 2012 Olympic Games.
      chiropractic teams were not ubiquitously available to all athletes and staff.
      Assessing and reporting on pretreatment and posttreatment pain self-reported by patients can be influenced by several factors beyond the treatment itself. Pain reports can be influenced by patient expectations, social support provided by the treatment team, the placebo effect, and even the desire to appease the patient’s DC.
      • Pariente J
      • White P
      • Frackowiak RSJ
      • Lewith G
      Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture.
      • Atlas LY
      • Wager TD
      • Dahl K
      • Smith EE
      Placebo effects.
      • Atlas LY
      • Wager TD
      How expectations shape pain.
      • Brown JL
      • Sheffield D
      • Leary MR
      • Robinson ME
      Social support and experimental pain.
      • Weeks WB
      • Goertz CM
      • Meeker WC
      • Marchiori DM
      Public perceptions of doctors of chiropractic: results of a national survey and examination of variation according to respondents' likelihood to use chiropractic, experience with chiropractic, and chiropractic supply in local health care markets.
      To protect against some of these influences, patients were allowed to complete their pain rating while not in the direct presence of the DCs, and the 2 VAS ratings were provided immediately before and immediately after treatment. However, these measures do not protect against the potential influences of social support or the placebo effect, and thus these factors should be primary targets of future research. We were also limited in determining the long-range effects of treatment because the posttreatment VAS rating was provided immediately after treatment. The nature of a multisport international event does not allow for long-term follow-up and reporting mechanisms. We acknowledge that our measurement of perceived pain is limited to the patient’s immediate perception and does not predict long-term outcomes.
      Although reductions in average pain levels were considered clinically significant, it is important to note that we cannot claim that chiropractic care affected facets of patients’ overall health beyond their experience of pain, such as their level of functioning or their athletic performance, given that we did not collect outcome measures other than perceived pain.

      Future Studies

      Recommendations for future studies include evaluating the value of chiropractic care in other national and international sporting events, such as the championship events of individual sport federations (eg, International Softball Federation or International Sailing Federation) and multisport events, such as the Commonwealth Games and the Master’s Games. Expanding reports of chiropractic use at athletic events may provide additional insight into the demographics of individuals who seek chiropractic care, treatment methodology, and efficacy. This information could be disseminated to federations and athletes to assist coaches and trainers in tailoring their training, strength and conditioning programs, and rehabilitation plans specifically to each sport.
      • Finch CF
      Getting sports injury prevention on to public health agendas—addressing the shortfalls in current information sources.
      By including additional features, these studies could extend, in several compelling ways, the findings we have presented here. More objective and diverse assessments of health and athletic performance outcomes beyond perceived pain should be collected. Sports medicine is primarily focused on improving performance measures; consequently, this information would be invaluable for evaluating the broader impacts and value of chiropractic care at sporting events.
      • Shekelle PG
      • Brook RH
      A community-based study of the use of chiropractic services.
      Researchers could investigate whether pain scores and other outcome measures differ among treatments provided by medical doctors, physiotherapists, and chiropractors. It is possible that different types of injuries are most successfully treated by different disciplines.
      Future studies could explore the relationship between the availability of chiropractic care and the use of this care. Studies could randomly assign chiropractic providers to sporting venues to compare utilization rates among athletes stationed at venues where DCs were or were not present. It would also be valuable to document whether the presence of a centralized treatment site improves overall use by athletes and non-athletes. Future studies could also compare the completeness of electronic data collection methods with data collected by paper-based methods. In particular, studies could test whether electronic methods expedite data collection and increase the proportion of viable data.
      • Derman W
      • Schwellnus M
      • Jordaan E
      • et al.
      Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff.
      Future studies could investigate patients’ motivations to seek chiropractic care (eg, pain reduction, improved performance, instructions of coaches, free treatment). This investigation may provide insight into athletes’ motivation to seek care, which would help identify best practices for providing chiropractic care at athletic events and potentially guide how coaches and sports medicine providers encourage use of chiropractic care. Finally, a larger delegation of DCs and researchers would assist in addressing completeness and quality of data collection.

      Conclusions

      The majority of people seeking chiropractic care at TWG2013, an international sporting competition, were athletes. Among those seeking care, the injury rate was higher in athletes compared with non-athletes. The majority of patients who received chiropractic care reported improvement immediately after receiving care.

      Funding Sources and Conflicts of Interest

      No funding sources or conflicts of interest were reported for this study.

      Contributorship Information

      • Concept development (provided idea for the research): D.D.N., B.C.N.
      • Design (planned the methods to generate the results): D.D.N., B.C.N.
      • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): D.D.N., B.C.N.
      • Data collection/processing (responsible for experiments, patient management, organization, or reporting data): D.D.N., B.C.N.
      • Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): E.C.N.
      • Literature search (performed the literature search): D.D.N., B.C.N., E.C.N.
      • Writing (responsible for writing a substantive part of the manuscript): D.D.N., B.C.N., E.C.N.
      • Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): D.D.N., B.C.N., E.C.N.

      Practical Applications

      • At the World Games 2013 held in Cali, Colombia, 1463 recorded chiropractic treatments were provided for athletes and non-athletes.
      • Athletes from 28 of 33 sports received treatment, and those from 68 of 93 countries were treated.
      • Analysis of pretreatment and posttreatment pain scores revealed an 87% reduction in perceived pain.

      Acknowledgments

      The authors thank Inga Gossow, Martin Isaksson, Laura Maurice, Rune Finne, and Anders Liverod for their assistance with data collection and processing. The authors also thank the 40 members of the FICS Chiropractic Delegation for providing care and assisting with data collection

      References

        • Engebretsen L
        • Steffen K
        • Alonso JM
        • et al.
        Sports injuries and illnesses during the Winter Olympic Games 2010.
        Br J Sports Med. 2010; 44: 772-780
        • Grant M-E
        • Steffen K
        • Glasgow P
        • Phillips N
        • Booth L
        • Galligan M
        The role of sports physiotherapy at the London 2012 Olympic Games.
        Br J Sports Med. 2014; 48: 63-70
        • Vanhegan IS
        • Palmer-Green D
        • Soligard T
        • et al.
        The London 2012 Summer Olympic Games: an analysis of usage of the Olympic Village “Polyclinic” by competing athletes.
        Br J Sports Med. 2013; 47: 415-419
        • Derman W
        • Schwellnus M
        • Jordaan E
        • et al.
        Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff.
        Br J Sports Med. 2013; 47: 420-425
        • Junge A
        • Engebretsen L
        • Alonso JM
        • et al.
        Injury surveillance in multi-sport events: the International Olympic Committee approach.
        Br J Sports Med. 2008; 42: 413-421
        • Mącznik AK
        • Schneiders AG
        • Sullivan SJ
        • Athens J
        What “CAM” we learn about the level of evidence from 60 years of research into manipulative and body-based therapies in sports and exercise medicine?.
        Complement Ther Med. 2014; 22: 349-353
        • Xue CCL
        • Zhang AL
        • Lin V
        • Myers R
        • Polus B
        • Story DF
        Acupuncture, chiropractic and osteopathy use in Australia: a national population survey.
        BMC Public Health. 2008; 8: 105
        • Ni H
        • Simile C
        • Hardy AM
        Utilization of complementary and alternative medicine by United States adults: results from the 1999 national health interview survey.
        Med Care. 2002; 40: 353-358
        • Hurwitz EL
        Epidemiology: spinal manipulation utilization.
        J Electromyogr Kinesiol. 2012; 22: 648-654
        • Astin JA
        Why patients use alternative medicine: results of a national study.
        JAMA. 1998; 279: 1548-1553
        • Goertz CM
        • Long CR
        • Hondras M
        • et al.
        Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.
        Spine. 2013; 38: 627-634
        • Rubinstein SM
        • van Middelkoop M
        • Assendelft WJJ
        • de Boer MR
        • van Tulder MW
        Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review.
        Spine. 2011; 36: E825-E846
        • Koes BS
        • Assendelft WJ
        • van der Heijden GJ
        • Bouter LM
        • Knipschild PG
        Spinal manipulation and mobilization for back and neck pain: a blinded review.
        BMJ. 1991; 303: 1298-1303
        • Meeker WC
        A meta-analysis of clinical trials of spinal manipulation.
        J Manipulative Physiol Ther. 1992; 15: 181-194
        • Meade TW
        • Dyer S
        • Browne W
        • Frank AO
        Randomised comparison of chiropractic and outpatient management for low back pain: results from extended follow up.
        BMJ. 1995; 311: 349-351
        • Legorreta AP
        • Metz D
        • Nelson CF
        • Ray S
        • Chernicoff HO
        • DiNubile NA
        Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.
        Arch Intern Med. 2004; 164: 1985-1992
        • Finch CF
        Getting sports injury prevention on to public health agendas—addressing the shortfalls in current information sources.
        Br J Sports Med. 2012; 46: 70-74
        • Kazemi M
        • Shearer H
        Chiropractic utilization in Taekwondo athletes.
        J Can Chiropr Assoc. 2008; 52: 96-102
        • Stump JL
        • Redwood D
        The use and role of sport chiropractors in the National Football League: a short report.
        J Manipulative Physiol Ther. 2002; 25: A2-A5
        • Nook B
        • Nook D
        Demographics of athletes and support personnel who used chiropractic physicians at the 6th All Africa Games.
        J Sports Chiropractic Rehabil. 1997; 11: 4
        • Nook DD
        • Nook BC
        A report of the 2009 World Games injury surveillance of individuals who voluntarily used the International Federation of Sports Chiropractic delegation.
        J Manipulative Physiol Ther. 2011; 34: 54-61
        • O’Halloran J
        • Miller GC
        • Britt H
        Defining chronic conditions for primary care with ICPC-2.
        Fam Pract. 2004; 21: 381-386
        • Hawker G
        • Mian S
        • Kendzerska T
        • French M
        Measures of adult pain.
        Arthritis Care Res. 2011; 63: 240-252
        • Bijur P
        • Silver W
        • Gallagher E
        Reliability of the visual analog scale for measurement of acute pain.
        Acad Emerg Med. 2001; 8: 1153-1157
        • Johnson C
        Measuring pain. Visual Analog Scale versus numeric pain scale: what is the difference?.
        J Chiropr Med. 2005; 4: 43-44
        • Cohen J
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum Associates, Inc., Hillsdale, NJ1988
        • The International Federation of Sports Chiropractic
        Welcome to FICS.
        (Available at:) (Accessed March 2, 2015)
        • Peregoy JA
        • Clarke TC
        • Jones LI
        • Stussman BJ
        • Nahin RL
        Regional variation in use of complementary health approaches by U.S. adults.
        NCHS Data Brief. 2014; : 1-8
        • Shekelle PG
        • Brook RH
        A community-based study of the use of chiropractic services.
        Am J Public Health. 1991; 81: 439-442
        • Whedon JM
        • Song Y
        • Davis MA
        • Lurie JD
        Use of chiropractic spinal manipulation in older adults is strongly correlated with supply.
        Spine (Phila Pa 1976). 2012; 37: 1771-1777
        • Theberge N
        The integration of chiropractors into healthcare teams: a case study from sport medicine.
        Sociol Health Illn. 2008; 30: 19-34
        • Pariente J
        • White P
        • Frackowiak RSJ
        • Lewith G
        Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture.
        NeuroImage. 2005; 25: 1161-1167
        • Atlas LY
        • Wager TD
        • Dahl K
        • Smith EE
        Placebo effects.
        in: Cacioppo JT Berntson GG Handbook of Neuroscience for the Behavioral Sciences. John Wiley & Sons, Inc., Hoboken, NJ2009: 1236-1259
        • Atlas LY
        • Wager TD
        How expectations shape pain.
        Neurosci Lett. 2012; 520: 140-148
        • Brown JL
        • Sheffield D
        • Leary MR
        • Robinson ME
        Social support and experimental pain.
        Psychosom Med. 2003; 65: 276-283
        • Weeks WB
        • Goertz CM
        • Meeker WC
        • Marchiori DM
        Public perceptions of doctors of chiropractic: results of a national survey and examination of variation according to respondents' likelihood to use chiropractic, experience with chiropractic, and chiropractic supply in local health care markets.
        J Manipulative Physiol Ther. 2015; 38: 533-544