The Benefits of Interprofessional Care.

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Overview - 5 sections

• About chiropractic
• Chiropractic in Ontario
• Evidence-based practice
• Recent data
• Models of interaction

About Chiropractic

SECTION 1

Chiropractic Care

• Assessment, diagnosis and treatment of neuromusculoskeletal disorders resulting from conditions affecting joints, ligaments, tendons, muscles, and nerves.
• Treatment and management of such conditions / disorders, primarily with the use of manual therapies including manipulation.
• Nutrition, therapeutic exercise, lifestyle counselling, and ergonomic recommendations.

Chiropractic Facts: Canada

• 6,000+ regulated practitioners
• 4.5 million+ Canadians visit a DC each year
• 88% of patients between 20 and 50 years old
• Most common condition treated: musculoskeletal injuries and complaints (96%)

Chiropractic Education in Canada

4 year - 4,500 hour program at accredited college (12 in North America)

• Canadian Memorial Chiropractic College (Toronto)
• Université du Québec à Trois-Rivières

Prerequisites for admission:

• 3 years university (non specific); minimum GPA 2.5
• Actual 2003 acceptance statistics: GPA 3.43, 85% Bachelors degrees, 15% Masters degrees, Average age 25 years.

Academic Program

First professional baccalaureate degree.

Multi-disciplinary faculty and training:

• Anatomy, biochemistry, physiology, neurology, radiology, immunology, microbiology, pathology and clinical sciences linked to diagnosis.

4th year – internship:

• Multidisciplinary facilities, Clinical rounds, Competency based assessment

Chiropractic in Ontario

SECTION 2

Chiropractic Facts: Ontario

• 3,000+ regulated practitioners
• 1.2 million Ontarians visit a DC each year
• 30% of Ontarians with joint/limb disorders
• Patient profile:
  • Female ~ male
  • Educated, mid-income, skilled/professional
  • ~ 75% are between 20 and 60 years old

Scope of Practice: Ontario

“The practice of chiropractic is the assessment of conditions related to the spine, nervous system and joints, and the diagnosis, prevention and treatment, primarily by adjustment, of:

Dysfunctions or disorders arising from the structures or functions of the spine and the effects of those dysfunctions or disorders on the nervous system; and,

Dysfunctions or disorders arising from the structures or functions of the joints.”

- The Chiropractic Act

Chiropractic in Ontario

Controlled acts

• Diagnosis
• Spinal adjustment

Licensing and Regulation

Licensure

• Canadian Chiropractic Examining Board (www.cceb.ca)
  • Canadian National Board Exams (Written)
  • Clinical Competency Examinations (Practical)

Regulation

• College of Chiropractors of Ontario (www.cco.on.ca)
• Provincial Licensing Examination

Distribution of complaints

Shekelle et. al., 1998

• Duration: 50% < 3 weeks; 25% > 12 weeks
• Onset: 26% significant trauma

Treatment Modalities

Treatment Goals

Acute Care:

• Relieve Pain
• Reduce muscle spasm and inflammation
• Increase flexibility
• Restore function and range of motion
• Treatment frequency reduced as progress made

Return to normal activities of daily living as quickly as possible.

Treatment Goals

• Rehabilitation
  • Stabilize
  • Increase strength
  • Maintain flexibility
• Prevention
  • Correct habits
  • Ergonomic modification
  • Minimize recurrences

Evidence-based Practice

SECTION 3

What is spinal adjustment or manipulation?

• Precise procedure, generally applied by hand to the joints.
• Force and technique modified to patient age, stature and condition.
• Improves joint mobility by restoring the range of motion, reducing muscle hypertonicity thereby relieving pressure and tension.

Manipulation vs. Mobilization

Stages of adjustment and definition of joint manipulation (Sandoz R.)

Rationale for Manipulative Therapy

Low Back Pain Trials

• Excess of 45 RCT's
• Meta-analysis (Cochrane Collaboration)
• Systematic analytical reviews (Van Tulder, 1996)
• Multi-discipline overviews
  • Rand (Shekelle 1992)
  • AHCPR (Bigos 1995)

Rationale for Manipulative Therapy

Cervical Spine Trials

• < 10 RCT's for neck pain and SMT (spinal manipulative therapy)
• Meta-analysis (Cochrane Collaboration, 2003)
• Systematic analytical reviews (Hurwitz 1997)
• Multidiscipline overview: Quebec Task Force on Whiplash, 1995
  • Evidence not as robust as for LBP
  • Generalizability to LBP trials?

Adverse Events

• Muscular soreness or stiffness - Majority of events
• Sprain / strain
• Temporal Association (not necessarily causal)
  • Disc injury/herniation
  • Rib fractures - Associated with Osteoporosis
• Vertebral artery dissection that may lead to stroke (Infarction) associated with cervical manipulation
  • Estimates vary and epidemiologists report that the rarity makes it difficult to study
  • The majority of data available puts the temporal risk around 1 in 1,000,000 to 1 in 2,000,000

Adverse Events

• Biomechanical studies at University of Calgary by Dr. Herzog illustrate for vertebral artery damage to occur a strain of 53% must occur while traditional cervical adjustments produce an average strain of 6% at most
• Risks are low:
  • Lower than most alternatives for similar conditions
  • All healthcare procedures/interventions carry risk what maters is that the benefit outweighs the risk
  • Recent CPG's on chiropractic care clearly outline the benefits while also providing guidelines on the risks
  • Profession is committed to ensuring members are fully aware (seminars, CPG’s, informational updates . . .) of those individuals who might be presenting with symptoms of arterial dissection and or stroke and encouraging the appropriate referral

Evidence Summary

Strong support for efficacy of conditions making up highest proportion of cases seen by chiropractors.

Recent Data

SECTION 4

Ontario WSIB

• Key findings from Program of Care for Acute Lower Back Injuries (POC for ALBI)
• Comparison of select program of care outcomes for chiropractic and physiotherapy patients
• Chiropractic patients:
  • Received more timely care with an average 3 days vs. Physio: average 13 days
  • Returned to work earlier with an average 9 days vs. Physio: average 20 days
  • Recovered more quickly where 11% of patients required care beyond 12 weeks vs. 22% of Physio patients

Manitoba WCB

Average days lost on the left versus average cost per claim on the right.

Effectiveness: US Evidence

Archives of Internal Medicine

• “Comparative Analysis of Individuals With and Without Chiropractic Coverage: Patient Characteristics, Utilization and Costs” (Oct 2004) Legoretta AP. Metz RD, et. al.

Retrospective study of claims data

• 1.7 million insured workers: 700,000 with chiropractic coverage and 1 million without chiropractic coverage

Legoretta & Metz

• Key findings:
  • Access to chiropractic care “clinically beneficial... may also reduce overall health care costs”
  • Plans that covered chiropractic care saved: 12% in costs to treat neuromusculoskeletal disorders and 1.6% in overall health insurance costs
• Drivers:
  • Positive risk selection (patients)
  • Substitution (lower cost than traditional medical care)
  • More conservative (less invasive treatment profiles)
  • Lower health service costs (fees)

Models of Interaction

SECTION 5

Indications for Referral

• Back pain and Sciatica
• Neck pain
• Headache
• Repetitive strain injuries
• Myofascial pain syndromes
  • Including whiplash/WAD injuries, sports injuries, and tension headaches with myogenic triggers
• Extremity injuries/MSK disorders

Referrals: What to Expect

• Thorough differential diagnosis
• Radiology – if necessary (14%)
• Informed consent to treatment
• Brief report back to MD on clinical findings
  • Initial, update, discharge
• Outcome-based therapy
  • Discharge patient after complaint resolves
  • Supportive care for chronic recurrent conditions
  • If patient not progressing favourably, will refer back to MD

Collaborative Care: Patient-Centred Model

Models of interaction: putting it all together.

Contact Dr. Robert Evans

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| Email Dr. Robert Evans | torontochiropractor.ca home |

Call: 416.598.4999 Fax: 416.598.0606

Related Links:

| Ontario Chiropractic Association | Canadian Chiropractic Association |