Approaches to Chiropractic Care in Aging Patients

Chiropractors play a key role in the management of musculoskeletal conditions in aging populations (Hawk et al., 2010). However, due to age-related physiological changes such as decreased bone density and increased tissue fragility, aging patients may face a higher risk of adverse effects from manual therapies-including fractures or hematomas. To ensure patient safety, clinical guidelines recommend adjusting both the selection and intensity of manual interventions for these individuals.

Although chiropractors report adapting their treatments based on age and perceived physical condition, the specific clinical and contextual factors influencing these therapeutic decisions remain poorly understood (Caissy et al., 2024). Perceived patient frailty, body type, and the chiropractor's own clinical experience may all play a role in guiding these choices. Furthermore, while it is assumed that adaptations in technique reflect a reduction in applied force, it is not yet established whether such adjustments result in measurable changes in treatment intensity compared to care provided to younger adults.

This observational study aims to address this gap by examining the factors that influence chiropractors' therapeutic decision-making when delivering manual therapies to both adult and aging patients. In parallel, it will assess whether clinical adaptations are associated with measurable differences in the force applied during treatment.

The primary objective is to identify clinical and contextual factors that influence chiropractors' therapeutic choices, especially when treating patients perceived as frail. The secondary objective is to compare the force applied during manual therapies between two age groups-patients aged 50 and older (aging group) and those aged 18-49 (younger adult group)-to determine if perceived adaptations correspond to actual reductions in applied force.

Hypotheses:

• Chiropractors will adjust their therapeutic choices based on clinical factors indicative of patient frailty, such as age, medical history, physical condition, and clinical presentation.
• The more fragile a patient is perceived to be (evaluated by the Pictorial Fit-Frail Scale and the Clinical Frailty Scale), the more likely the chiropractor will choose techniques considered safer and lower in applied force.
• On average, the force applied during manual therapy will be lower for aging patients compared to younger adults.

Study Design and Procedures:

This study will be conducted in real-world clinical settings in Quebec. The chiropractor is the primary study participant, with the patient acting as a contextual intermediary, receiving their usual care. No modifications to clinical judgment or treatment type will be imposed.

Chiropractors who consent to participate will meet with the lead researcher to review study objectives, data collection procedures, and informed consent procedures. The discussion will help integrate the study into the clinical workflow with minimal disruption. During the data collection day, the chiropractor will treat patients as usual. A researcher will be present to observe the session and place a force sensor beneath the patient if applicable, depending on the treatment type. After each treatment, the chiropractor will complete a short questionnaire (<10 minutes) about the session. At the end of the day, a brief review and clarification session with the researcher (~10 minutes).

Patients will have been informed in advance (via phone, prior visit, or reception staff) that a research project may be taking place during their upcoming visit. On the day of data collection, they will have access to an information sheet and may ask questions before giving informed consent. If they agree, they will receive their usual care, with the presence of a researcher during treatment. A force sensor may be placed under them, depending on the nature of the manual therapy. Participation may add 5-10 minutes to their normal visit duration. Patients will complete a brief 5-question questionnaire either before or after the treatment.

This protocol is designed to minimize disruption to clinical routines. Observing patient care in a natural setting is essential to collecting contextual and force-related data.

The results of this study will provide new insights into clinical reasoning and force modulation during chiropractic care for aging patients. These findings may inform the development of future clinical guidelines aimed at improving both safety and effectiveness of manual therapy in older adults.

Data Analysis : Descriptive statistics will be used to report sample characteristics of both chiropractors and patients. Manual therapy force (measured in Newtons) will be calculated using a MATLAB script developed by the research team, which identifies the peak force manually for each intervention.

To explore the factors influencing chiropractors' therapeutic choices (e.g., spinal manipulation, mobilization, instrument-assisted techniques, use of blocks), a Bayesian statistical approach will be employed. This method allows for the direct estimation of the probability of various predictor effects (e.g., patient age, gender, frailty score, height, weight), while accounting for inter-practitioner variability.