Introduction to Chiropractic

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 What is Chiropractic?
• Assessment, diagnosis and treatment of
neuromusculoskeletal disorders, primarily through
manipulation and other manual therapies.

• Treatment & management of conditions resulting from: joint,

ligament, tendon, muscle, nerve and spinal disorders; their
effect on the body & nervous system.

• Nutrition, therapeutic exercise, lifestyle & 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 of university study.
– Quebec: 5 year, full-time program at Université de Québec
a Trois Riviéres following graduation from CEGEP.
– Multidisciplinary faculty and training: anatomy,
biochemistry, biomechanics, physiology, neurology,
radiology, immunology, microbiology, pathology, clinical
nutrition and clinical sciences specifically relating to
diagnosis.
 Chiropractic Regulation
• 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 and
Educational Accrediting Boards (CFCREAB) provides a
national forum for the provincial colleges
• Three standardized national exams (clinical competency and
written cognitive) plus licensure exam conducted in province
of practice.
 Chiropractic Facts
• Canadian practitioners: 7,800

• Utilization: 4.5 million Canadians/year

• Average patient load/week fulltime DCs (2011 CCRD): 111

• Average fee /visit: $40 to $45

• Most common conditions treated: musculoskeletal injuries &

complaints (87%)
 Health Plan Coverage
• Covered by some provincial health care plans.

• 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.

 Chiropractic & WCB
• All provincial Worker Compensation Boards utilize
chiropractic to treat injured workers.

• Data consistently illustrates chiropractic’s 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 - 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
 Scientific Support
• 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.
 Diagnosis
• Trained and licensed to perform differential diagnosis:
– Clinical history, MSK assessment, posture/palpatory
examination, radiology if indicated

• Is this musculoskeletal (not pathological)?

• What is the specific functional disorder?

Chiropractic Treatment Modalities
• Manual Care: • Adjunctive Therapies:
– Adjustment (90%), – Ultrasound, TENS, IFC,
mobilization, myofascial laser etc.
release techniques
– Ice, heat, massage etc.
– Instrument assisted soft
tissue – Acupuncture

• Exercise: • Education:
– Instruction and/or – Condition specific:
supervision (75%) lifestyle, ergonomics,
– Rehabilitation nutrition
 Indications for Referral
• Back pain/sciatica

• Neck pain

• Headache

• Repetitive strain injuries

• Myofascial pain syndromes

• Conditions of the extremities

 Treatment Goals
• Acute Care:
– Relieve pain
– Reduce muscle spasm and inflammation
– Increase flexibility
– Restore function and range of motion

Return to normal activities of daily living

as quickly as possible
 Treatment Goals cont’d
• Rehabilitation
– Stabilize
– Increase strength
– Maintain flexibility

• Prevention
– Correct habits
– 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

 Back Pain
• Most common condition treated.

• According to the Institute for Work & 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

 Expert Reviews
• 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 cont’d
• 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.
 Neck Pain
• Prevalence:*
– Lifetime 65%
– Chronic 10%

• Cochrane review of spinal manipulative therapy and

mobilization for mechanical neck pain: Multi-modal care
(SMT/Mobs) plus exercise is more effective than
physiotherapy or usual care.*

* Cote et al. Pain, 2004

* Gross et al. Spine, 2004
 Myofascial Conditions
• Tension headache with myogenic trigger

• Sports injuries

• Repetitive strain injuries

• Whiplash and whiplash associated disorder injuries

 Adverse Affects
• Short-term muscle soreness or stiffness

• Rib fracture

• TIA/dissection
 Risk Rates
• Serious adverse events associated with cervical manipulation
are rare:
– Estimates vary
– One to two events per million cervical adjustments

• There was an association between chiropractic visits and a

similar association observed among patients receiving general
practitioner services. This is likely explained by patients with
vertebrobasilar artery dissection-related neck pain or
headache seeking care before having a stroke.

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
Haldemann et al. Spine 2008
 What to expect when referring
• 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