Introduction
In Canada, the senior population of adults aged 65 years and older is expected to increase by 68% over the next 20 years (Canadian Institute for Health Information, 2017). A major health concern for this growing population is chronic pain, which affects one in three adults 65 and older (Canadian Pain Task Force, 2021; Schopflocher et al., Reference Schopflocher, Taenzer and Jovey2011). Musculoskeletal burdens, including low back pain and arthritis, are common health complaints among older adults in Canada (D’Astolfo & Humphreys, Reference D’Astolfo and Humphreys2006). The prevalence and severity of chronic pain increases with age and disproportionately affects women (Schopflocher et al., Reference Schopflocher, Taenzer and Jovey2011). Additionally, chronic pain has a higher prevalence and severity among certain Indigenous peoples, individuals with substance use disorder, and those in poverty (Dassieu et al., Reference Dassieu, Kaboré, Choinière, Arruda and Roy2019; Jimenez et al., Reference Jimenez, Garroutte, Kundu, Morales and Buchwald2011). Older adults are more likely to suffer from low back pain if they have a lower educational status, are former blue-collar workers, or are low-income (Atkins & Mukhida, Reference Atkins and Mukhida2022; Ikeda et al., Reference Ikeda, Sugiyama, Aida, Tsuboya, Watabiki and Kondo2019).
Community health centres (CHC) in Canada provide collaborative primary care, health promotion, community programs, and social services to marginalized communities (Najafizada et al., Reference Najafizada, Bourgeault, Labonté, Packer and Torres2015). Mount Carmel Clinic (MCC), established in 1926, was Canada’s first CHC and provides community-focused care in Winnipeg, Canada (Mount Carmel Clinic, n.d.). In 2011, MCC launched a pilot program to provide chiropractic services. Since then, studies have demonstrated reductions in acute and chronic spine and extremity pain, high patient satisfaction, and a decrease in other clinical services such as primary care visits among chiropractic patients at MCC (Manansala et al., Reference Manansala, Passmore, Pohlman, Toth and Olin2019; Passmore et al., Reference Passmore, Toth, Kanovsky and Olin2015; Passmore et al., Reference Passmore, Malone, Manansala, Ferbers, Toth and Olin2022).
In 2018, the Canadian Medical Association (CMA) reported concerns over the publicly funded system’s ability to care for an aging population. At that time, seniors constituted one-fifth of the Canadian population but consumed half of healthcare spending (Gibbard, Reference Gibbard2018). The CMA reported provincial and territorial governments will need an additional $93 billion before 2030 to meet the health care needs for seniors. They cited musculoskeletal pain as the third most expensive condition experienced by older adults in the Canadian healthcare system, after cancer and heart disease (D’Astolfo & Humphreys, Reference D’Astolfo and Humphreys2006). This underscores the need for safe and effective interventions, coordinated into mainstream care delivery, to address the growing burden of musculoskeletal conditions among older Canadians.
Multiple low back pain guidelines, including the American College of Physicians, recommend nonpharmacological therapies as first-line treatments, including spinal manipulation, acupuncture, and exercise, which are common in chiropractic practice (Bussières et al., Reference Bussières, Stewart, Al-Zoubi, Decina, Descarreaux and Haskett2018; Foster et al., Reference Foster, Anema and Cherkin2018; Qaseem et al., Reference Qaseem, Wilt, McLean and Forciea2017; World Health Organization [WHO], 2023). In the United States, older adults under the federal healthcare system who presented to a chiropractor first for spinal pain saw decreases in low-value, high-risk interventions for back pain, including opioid exposure, advanced imaging, and injections (Horn et al., Reference Horn, George and Fritz2017; Weeks et al., Reference Weeks, Leininger, Whedon, Lurie, Tosteson and Swenson2016; Whedon et al., Reference Whedon, Uptmor, Toler, Bezdjian, MacKenzie and Kazal2022).
The primary objective of this study was to describe the characteristics, clinical management, and patient-reported outcomes of older adults with spinal and other musculoskeletal pain who presented for chiropractic care at a publicly funded healthcare facility. Our secondary objective was to determine if there are differences between age cohorts across time.
Methods
Study design
The study retrospectively analyzed quality assurance data from the Mount Carmel Clinic. Data were extracted from chiropractic clinical encounters between January 2011 and June 2020. The University of Manitoba’s Research Ethics Board approved all procedures, and formal permission was obtained from the officer of records at MCC prior to data extraction and analysis. We adhered to the STROBE checklist in the design and reporting of the study.
Setting
Mount Carmel Clinic is in the Point Douglas neighbourhood of Winnipeg, Manitoba. The Point Douglas neighbourhood has the highest percentage of Indigenous residents, low-income residents, lowest proportion of residents with a post-secondary education, highest unemployment rate, and highest rate of substance use disorder in the Winnipeg Health Region (Cui et al., Reference Cui, Zinnick, Henderson and Dunne2019).
The clinic offers a wide range of services, including, but not limited to, primary care, chiropractic, nutritional counselling, and dental services without charge to patients. To qualify for these services, patients must be deemed to be at a financial disadvantage and not covered by any additional third-party reimbursement by employee benefits. The chiropractor employed at MCC receives an hourly wage and has no financial incentive to see patients beyond a plateau of clinical improvement. Quality assurance data has been collected since chiropractic was offered as a service in 2011.
Participants and variables
The study sample included patients aged 45 years and older who presented to MCC for chiropractic services. Patients consented to treatment before initiating a course of care. After examination, if chiropractic care was not indicated, then patients were referred to an appropriate health care provider.
For the purposes of this study, middle-age was defined as age 45–59 years; older adults were defined as those age 60 years and older. Patient demographic data were collected during the initial visit to the chiropractic clinic and stored in a quality assurance database. Based on patient self-report of height and weight, body mass index (BMI) was calculated.
Pain score by region was collected. Pain severity scores reflected current pain that day and were recorded using the pain numeric rating scale (NRS), an 11-point Likert scale with 0 representing ‘no pain’ and 10 representing ‘worst pain possible’ (Downie et al., Reference Downie, Leatham, Rhind, Wright, Branco and Anderson1978). Chiropractic patients were asked to rate their pain at their initial visit, every fifth visit, and at discharge from care. Patients were excluded from this study if they did not complete outcome scores.
Data source
The data are maintained through the MCC chiropractic program by the treating clinician on site. Patient data were de-identified upon entry to the database prior to analysis and interpretation.
Chiropractic treatment methods and frequency
Patients undergoing chiropractic treatment received an individualized, pragmatic course of care provided by a licensed chiropractor aligned with guideline driven practices (Bussières et al., Reference Bussières, Stewart, Al-Zoubi, Decina, Descarreaux and Haskett2018; Foster et al., Reference Foster, Anema and Cherkin2018; Qaseem et al., Reference Qaseem, Wilt, McLean and Forciea2017; WHO, 2023). Chiropractic care included several different treatment options, including joint manipulation and mobilization, soft tissue therapy, acupuncture, and other adjunctive and supportive therapies. Patients were re-evaluated every 5 treatment visits to assess whether their symptoms were better, worse, or unchanged. Additionally, during re-evaluation visits, patients were assessed to determine if a referral to another provider was warranted. Initial visits were scheduled for 30–60 min, and re-evaluation visits were scheduled for 15–30 min. Subsequent follow-up treatment visits were scheduled for 15–30 min.
Statistical analysis
Analysis of raw numbers and percentages was achieved using descriptive statistics to describe the characteristics of the total population, clinical presentation, and clinical management (Tables 1, 2, and 3). Clinical management includes referral options, radiographs, and clinical treatment.
Table 1. Patient Characteristics – Chiropractic patient demographic and clinical characteristics of middle-age and older adult’s visits at the Mount Carmel Clinic from 2011 to 2020
Note: Not all patients completed all fields.
a Participants self-reported.
b At the time these data were collected patients only had the option to select Aboriginal, we understand the term Indigenous is culturally appropriate.
c Employment at first visit.
Table 2. Clinical encounter
Abbreviations: ER = emergency room, DC = Doctor of Chiropractic, PCP = primary care provider, HP = health professional.
Table 3. Treatment intervention: n (%)
We considered all patient datasets of adults, aged 45 years and older, who initiated chiropractic treatment at MCC between January 2011 and June 2020. Any deviation of the sample size was due to patients abstaining from certain questions or receiving care in limited regions of complaint.
In alignment with the Canadian Guidelines for Body Weight Classification in Adults, BMI was classified into four categories (kg/m2): (1) underweight (<18.5); (2) normal weight (18.5–24.9); (3) overweight (25.0–29.9); and (4) obese (30.0+) (Health Canada, 2003). The classification system does consider that persons 65 years and older have a slightly different and higher range of ‘normal’ that may extend into ‘overweight’ range.
Acute pain was defined as pain lasting less than 3 months in duration, while chronic pain was defined as pain occurring for a period lasting 3 months or longer (King, Reference King, Gebhart and Schmidt2013). Pain duration was described within each age group and expressed as a ratio.
All statistical analyses were calculated using either jamovi (The jamovi project, 2021, version 1.6.23) or R Statistical Software (R Core Team 2023, version 4.2.3) with an alpha set at 0.05. The five regions of treatment included: (1) cervical; (2) thoracic; (3) lumbar spine; (4) sacroiliac joint; and (5) extremity. A minimal clinically important difference (MCID) for low back pain with the NRS was established as a 30% improvement from baseline to discharge score (Ostelo et al., Reference Ostelo, Deyo, Stratford, Waddell, Croft and Von Korff2008). Proportional change was calculated as follows ([Baseline – Discharge]/Baseline) in pain by region. Student’s t-tests were run to compare raw score change in pain by region and separated by age categories (45 < 59 and ≥ 60) for the total sample of patients, as well as acute pain, and chronic pain.
Separate repeated-measures ANOVAs were conducted for each region’s raw score change (Baseline – Discharge) in pain. The ANOVA model allowed a comparison for pain between age groups and across time for each separate anatomical region.
Results
Participant demographics
From the original sample of 307 adults over age 45 who presented to MCC for chiropractic care, 240 unique patients attended both an initial and a follow-up visit and had complete data captured for the variables of interest. The mean age was 57.5 years (SD = 9.0; range 45–93). In this sample, the majority of adults were female (57.9%), Caucasian (47.1%), and obese (M = 30.2 kg/m2). When broken into age cohorts (Table 1), among middle-aged adults it was notable that 53.1% self-reported as Indigenous, 52.5% as people with disabilities/retired due to being a person with disabilities, and 11.1% were unhoused. Between the two age cohorts, both middle-aged adults (23.1%) and older adults (25.0%) utilized assisted living in similar patterns.
Participants commonly presented with additional comorbidities, including osteoarthritis (e.g. degenerative joint disease), hypertension, diabetes, depression and anxiety, and substance abuse (current or history of). About two-thirds of middle-aged (62.7%) and older adults (67.1%), respectively, were referred for chiropractic care by their primary care provider. Overwhelmingly, both middle-aged (79.1%) and older adults (89.0%) reported that a visit to the chiropractor saved them a subsequent visit to their primary care provider (Table 2). The chiropractic provider referred 8.9% of middle-aged and 9.8% of older adults to other providers for additional care at the end of a course of chiropractic management. Previous emergency room visits for the same complaint were reported by 8.5% of older adults (mean 2.4 visits) and 8.2% of middle-aged adults (mean 2.8 visits). Radiographs were required for 38.6% of middle-aged and 35.4% of older adults.
Common treatments included high-velocity, low-amplitude (HVLA) spinal manipulation, mobilization, and soft tissue therapy (Table 3). Between age cohorts, similar percentages of adults received HVLA spinal manipulation, mobilization, and soft tissue work across different regions. Spinal manipulation was performed on 96.3% of older adults and 98.7% of middle-aged adults among the different spinal regions and extremities. Differences emerged when considering acupuncture and exercise between age cohorts. Specifically, older adults were more likely to receive acupuncture compared to middle-aged adults. To the corollary, middle-aged adults were more likely to receive exercise compared to older adults.
When expressed as a ratio, chronic pain was more than twice as common compared to acute pain in both middle-aged and older adults in all 4 spinal regions and the extremities (Table 4). The greatest proportion of patients sought care for chronic pain in the lumbar spine region in both the older adult (63.4%) and middle-aged (70.3%) cohorts. Both age cohorts achieved MCID and statistically significant changes in pain across spinal regions and extremities associated with a course of care (Table 5). However, there were no significant main effects or interactions between age cohorts (Table 6). Categorically, each age cohort decreased from severe pain (NRS 7–10) at baseline to moderate pain (NRS 4–6) at discharge.
Table 4. Duration of complaint – Some patients have complaints in multiple regions. Acute <3 months and chronic ≥3 months
Table 5. Patient outcomes – Patient outcomes by region for the Pain Numeric Rating Scale (NRS): Mean (SD)
Note: CS is cervical spine, TS is thoracic spine, LS is lumbar spine, SI is sacroiliac region, Ext is extremity.
Table 6. Relationships for pain outcomes between region, time and age – repeated-measures ANOVA
Note: Time is between baseline to discharge NRS scores.
Patients seeking care for acute pain experienced the greatest decrease in NRS point change (Table 5). Middle-aged adults demonstrated statistically significant improvements in acute pain in all regions, while older adults saw statistically significant improvements in acute pain in all but the cervical spine region where there was still a trend toward statistical significance.
In the older adult cohort with chronic pain, MCID was achieved in the sacroiliac and extremity regions (Table 5). There was a trend toward but short of the MCID threshold in the cervical (by 0.8%), thoracic (by 1.8%), and lumbar regions (by 1.2%). In the middle-aged cohort with chronic pain, MCID was achieved in the cervical and sacroiliac regions. There was a trend toward but short of the MCID threshold in the thoracic (by 0.3%), lumbar (by 0.7%), and extremity regions (by 1.6%).
Discussion
Older adults from marginalized communities with socioeconomic challenges are seeking chiropractic care within a publicly funded facility and are reporting clinical and statistical improvements in pain. Regardless of the number of pain regions, older patients of any age may experience statistically and clinically important changes from their baseline pain in any single region.
The findings of the current paper align directly with the World Health Organization (WHO) guiding principles focused on (1) equity and (2) integrated and coordinated care for older adults and those with socioeconomic challenges (WHO, 2023). The Mount Carmel Clinic provides community-focused healthcare from a social equity approach, in this case providing chiropractic services to a population who may not otherwise be able to afford typical out-of-pocket healthcare expenses in Canada, such as chiropractic.
Characteristics
This study focused on individuals from marginalized communities where pain has been historically mismanaged and under addressed in the literature (Craig et al., Reference Craig, Holmes, Hudspith, Moor, Moosa-Mitha and Varcoe2020). Demographic characteristics of the present study within the middle-aged cohort, revealed a notable amount of the sample identified as Indigenous, or as people with disabilities /retired due to being a person with disabilities. While in the older cohort, the sample identified primarily as Caucasian and retired. Both age cohorts experienced chronic pain more commonly than acute pain across all regions. It is possible that chronicity reflects a generational shift in community demographics and lifestyle or could be attributed to older age (Statistics Canada, 2016, 2021).
Clinical management
The vast majority of older adults in this study reported that a visit to the chiropractor prevented a subsequent visit to their primary care provider. The substitution effect of chiropractic for primary care services has been previously documented among older adults in the US under the federal Medicare program (Davis et al., Reference Davis, Yakusheva, Gottlieb and Bynum2015; Reference Davis, Yakusheva, Liu, Anderson and Bynum2021). Such an allocation of services relieves the burden on primary care providers to see patients for non-musculoskeletal services while ensuring patients who attend chiropractic visits are receiving timely and effective care for spinal and extremity conditions. Radiographs were deemed required in approximately one third of this sample, which could reflect utilization of best practices for imaging (Hawk et al., Reference Hawk, Schneider, Haas, Katz, Dougherty and Gleberzon2017). The literature supports that early contact with a chiropractor is associated with guideline-concordant care and a decrease in downstream healthcare services and overall health system costs while improving efficiency for both the system and patient (Davis et al. Reference Davis, Yakusheva, Liu, Anderson and Bynum2021; Farabaugh et al., Reference Farabaugh, Hawk, Taylor, Daniels, Noll and Schneider2024; Stevans et al., Reference Stevans, Delitto, Khoja, Patterson, Smith, Schneider and Freburger2021). In a socioeconomically challenged population, community health centres have an opportunity to provide access to high value conservative care options for non-pharmacological pain management.
Spinal manipulative therapy was the most common therapeutic technique delivered to both middle-aged and older adults in this study. This choice of intervention by the study practitioner is supported by a 2019 systematic review of 47 randomized control trials, which concluded that spinal manipulative therapy produces similar effects for chronic low back pain to other recommended treatments such as exercise and pharmacological treatments (ie. non-steroidal anti-inflammatory drugs and analgesics) (Rubinstein et al., Reference Rubinstein, de Zoete, van Middelkoop, Assendelft, de Boer and van Tulder2019). Multiple clinical practice guidelines support spinal manipulative therapy as first-line intervention to address musculoskeletal spine complaints (Bussières et al., Reference Bussières, Stewart, Al-Zoubi, Decina, Descarreaux and Haskett2018; Foster et al., Reference Foster, Anema and Cherkin2018; Qaseem et al., Reference Qaseem, Wilt, McLean and Forciea2017; WHO, 2023). Older adults from marginalized populations, as seen in this study, have a higher incidence of complex comorbidities, but spinal manipulation was not necessarily contraindicated (Akinyemiju et al., Reference Akinyemiju, Jha, Moore and Pisu2016; Barnett et al., Reference Barnett, Mercer, Norbury, Watt, Wyke and Guthrie2012). Chiropractic intervention alleviates musculoskeletal pain and therefore may decrease the need for additional pharmaceuticals, which could lessen the burden of polypharmacy in older adults managing comorbid conditions.
Patient-reported outcomes (pain)
Similar to the current study, younger patients and women from socioeconomically challenged populations have also reported meaningful pain reductions following a course of chiropractic care (Manansala et al., Reference Manansala, Passmore, Pohlman, Toth and Olin2019; Morham et al., Reference Morham, Reichardt, Toth, Olin, Pohlman and Passmore2022). In the present study, while each age cohort saw statistically and clinically meaningful decreases in pain across spinal and extremity regions with treatment, there were no differences between age groups addressing our objective. Regardless of age, overall adult patients from this study with access to chiropractic care had the opportunity to reach a meaningful reduction in pain in any spinal or extremity region.
Limitations
Several limitations are inherent to a retrospective study design. This study had no control group, so we were unable to ascribe changes in condition directly to treatment. Data were limited to what was collected as part of the MCC quality assurance database, and patients could decline to answer any questions, which reduced the number of chiropractic patients who were included in this analysis. The pain outcomes were verbally reported by the patient and recorded by the treating clinician as part of their clinical encounter, potentially introducing both participant and clinician bias. Data are typically collected in the Mount Carmel Clinic in this manner to minimize data collection burden and mitigate the impact of patient literacy on the ability to collect clinical information and outcomes. Data extractors were not blinded to the study’s objectives. This sample includes adults from a socioeconomically challenged, underserved community with complex comorbidities that may not reflect the general adult population seeking chiropractic services. Congruent with clinical practice guideline recommendations, our sample population followed a pragmatic and multimodal approach to care, which included variations in treatments and visit frequency.
While the majority of findings are statistically significant, the sample sizes of some subpopulations by pain duration or region are small and results should be interpreted with caution. Had there been a larger sample size it is possible the trend in older adults with acute cervical pain would have achieved statistical significance. Management of chronic musculoskeletal pain is complex (El-Tallawy et al., Reference El-Tallawy, Nalamasu, Salem, LeQuang, Pergolizzi and Christo2021). Utilizing a different threshold may have influenced clinical significance (Salaffi et al., Reference Salaffi, Stancati, Silvestri, Ciapetti and Grassi2004).
Conclusion
Older adults with spinal and extremity region pain from a socioeconomically challenged population experienced statistically significant and clinically meaningful improvements in pain associated with a publicly funded pragmatic course of chiropractic care. Community health centres that integrate chiropractic services provide access to high-value conservative care to socioeconomically challenged populations who might otherwise not have the ability to obtain care due to financial or geographic barriers. Future research should explore experimental designs to investigate the safety, effectiveness, and cost of chiropractic care for older adults among other marginalized or medically underserved populations. Psychosocial factors, housing status, and social determinants of health pertinent to older adults should be considered.
Acknowledgment
The authors would like to thank the Mount Carmel Clinic for its ongoing support of this research and for providing the database records used in this analysis. We would like to acknowledge Dr. Audrey Toth, chiropractor at Mount Carmel Clinic, for data collection and entry.
Author contribution
AA: conceptualization, data curation, formal analysis, methodology, project administration, roles/writing – original draft, roles/writing – review & editing. MM: conceptualization, data curation, formal analysis, methodology, supervision, roles/writing – original draft, roles/writing – review & editing. GT: conceptualization, data curation, formal analysis, methodology, roles/writing – original draft, roles/writing – review & editing. SP: conceptualization, data curation, formal analysis, methodology, project administration, supervision, roles/writing – original draft, roles/writing – review & editing.
Competing interests
The authors report no conflicts of interest or funding sources for this study.
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