Introduction to Chiropractic for Medical Doctors.
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What is Chiropractic Care?
- Assessment, diagnosis and treatment of neuromusculoskeletal disorders, primarily through manipulation and other manual therapies.
- Treatment and management of conditions resulting from: joint, ligament, tendon, muscle, nerve, and spinal disorders; their effect on the body and nervous system.
- Nutrition, therapeutic exercise, lifestyle and ergonomic counselling.
Chiropractic Education (CDN)
Two degree-granting, full-time, accredited chiropractic programs:
- Ontario: 4 year, full-time program at the Canadian Memorial Chiropractic College following a minimum of three years university study.
- Quebec: 5 year, full-time program at Université de Québec a Trois Riviéres following graduation from CEGEP.
- Multi-disciplinary faculty and training: anatomy, biochemistry, physiology, neurology, radiology, immunology, microbiology, pathology, and clinical sciences specifically relating to diagnosis.
Chiropractic is a regulated health profession:
- Legislated scope of practice in all Provinces/Territories; controlled act of manipulation.
- Provincial regulatory colleges charged with licensing, continued competence and public protection.
- Canadian Federation of Chiropractic Regulatory Boards provides a national forum for the provincial colleges.
Two standardized national exams (clinical competency and written cognitive) plus licensure exam conducted in province of practice.
- Canadian practitioners: 6,000
- Utilization: 4.5 million Canadians per year
- Average patient visits per year: 12
- Average fee per visit: $30 to $40
- Most common conditions treated: musculoskeletal injuries and complaints (87%)
Health Plan Coverage
- Covered by some provincial health care plans (not Ontario).
- Widely covered under extended health care plans with majority of plans providing coverage of at least $500 per annum*.
- Covered by all Workers Compensation Boards and most automobile insurance plans.
- Included in federal programs, e.g. Veterans Affairs, RCMP, etc.
*Hewitt Associates SpecBok Survey 2003/04
Chiropractic and the WCB
- All provincial Worker Compensation Boards utilize chiropractic to treat injured workers.
- Data consistently illustrates chiropractic had high effectiveness in getting injured workers back to work.
- Other findings with WCB chiropractic patients*:
- Reduced time to care - average time to treatment 3 days.
- Reduced chronicity - only 11% required care beyond 12 weeks.
- Earlier return to work - median lost time 9 days.
*Ont. WSIB 2003 Program of Care Evaluation for Acute Low Back Injuries.
- Six formal government reviews (worldwide). All concluded that contemporary chiropractic care is safe and effective.
- Canadian Institute for Health Research partnerships with The Canadian Chiropractic Association to provide grants for chiropractic research.
- Canada Research Chair in Spinal Function awarded to Dr. Greg Kawchuk, DC.
- Trained and licensed to perform differential diagnosis:
- Clinical history, MSK assessment, neurological exam, posture/palpatory examination, radiology if indicated.
- Is this musculoskeletal (not pathological)?
- What is the specific functional disorder?
Chiropractic Treatment Modalities
- Manual Care: Adjustment (90%), mobilization, myofascial release techniques
- Adjunctive Therapies:
- Ultrasound, TENS, IFC, laser etc.
- Ice, heat, massage etc.
- Exercise: Instruction and/or supervision (75%).
- Education: Condition specific: lifestyle, ergonomics, nutrition.
Indications for Referral to a Chiropractor
- Low Back pain/sciatica
- Neck pain
- Shoulder, mid-back, inter-scapular pain
- Repetitive strain injuries
- Myofascial pain syndromes
- All conditions of the extremities, especially feet and forearms
- Acute Care:
- Relieve pain
- Reduce muscle spasm and inflammation
- Increase flexibility
- Restore function and range of motion
Return patients to normal activities of daily living as quickly as possible.
Treatment Goals continued
- Increase strength
- Maintain flexibility
- Correct habits, especially posture
- Ergonomic modification
- Minimize recurrences
Distribution of Complaints
- Duration: 50% < 3 wks; 25% >12 wks
- Onset: 26% significant trauma
Shekelle et al. Ann Intern Med 1998.
- Most common condition treated next to upper back, shoulder, interscapular pain.
- According to the Institute for Work and Health, low back pain affects 85% of the working population and is a leading cause of disability and absence.*
*Cassidy et al, Spine 1998.
UK BEAM Trial (2004)
- “... this is the first study ... to show convincingly that both manipulation alone and manipulation followed by exercise provide cost-effective additions to best care [for low back pain patients] in general practice.”
BMJ, Nov. 19, 2004
Legoretta et al (2004)
- Benefit plan members with chiropractic coverage vs. members without; 4 year study of low back pain related claims
- With chiropractic care:
- Reduced utilization of radiographs and MRI
- Reduced hospitalizations
- Reduced surgery
- Reduced costs
Legoretta et al. Arch Int. Med 2004
- U.K. Clinical Standards Advisory Group 1994: recommends manipulation with exercise and physical activity for low back pain.
- New Zealand Acute Low Back Pain Guide 1997: includes manipulation as appropriate treatment for acute low back pain.
Expert Reviews continued
- Danish Institute for Higher Technology Assessment 1999: adjustment is indicated for management of acute, recurrent and chronic low back pain.
- Ontario WCB Guidelines for Chronic Pain 2001: adjustment more effective for chronic low back pain than usual care, bed rest, analgesics or massage.
- Cochrane review of spinal manipulative therapy and mobilization for mechanical neck pain: Multi-modal care (Spinal Manipulative Thereapy/Mobilizations) plus exercise is more effective than physiotherapy or usual care.*
* Cote et al. Pain, 2004
* Gross et al. Spine, 2004
- Tension headache with myogenic trigger. Cervicogenic headaches common.
- Sports injuries.
- Repetitive strain injuries.
- Whiplash and whiplash associated disorder injuries.
- Short-term muscle soreness or stiffness.
- Rib fracture.
- Serious adverse events associated with cervical manipulation are rare:
- Estimates vary.
- The majority of data available puts the temporal risk around 1 in 1,000,000 to 1 in 2,000,000
Meeker WC, Haldeman S. Annals of Internal Medicine, 2002.
Rothwell DM, Bondy SJ, Williams JI. Stroke, 2001.
Herzog W, Symons BP, Leonard T. Journal of Manipulative and Physiological Therapeutics, 2002.
What to Expect When Referring
- Full cinical history, musculoskeletal physical examination, and diagnosis.
- Radiology – if necessary.
- Informed consent to treatment.
- MD communication (initial, update, discharge).
- Referral back if no progress, contraindications to care, or pathologies.
- Outcomes-based therapy.
Benefits of Collaborative Care
- Continuity of care.
- Timely assessment, treatment, and reporting.
- Network with other providers.
- Patient satisfaction.
© Dr. Robert J. Evans 2011