1. Introduction to Chiropractic Presentation to: Presented by:

2. 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

3. 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.

4. 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.

5. 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%)

6. 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.

7. 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

8. 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.

9. 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?

10. Chiropractic Treatment Modalities Manual Care: – Adjustment (90%), mobilization, myofascial release techniques – Instrument assisted soft tissue Exercise: – Instruction and/or supervision (75%) – Rehabilitation Adjunctive Therapies: – Ultrasound, TENS, IFC, laser etc. – Ice, heat, massage etc. – Acupuncture Education: – Condition specific: lifestyle, ergonomics, nutrition

11. Indications for Referral Back pain/sciatica Neck pain Headache Repetitive strain injuries Myofascial pain syndromes Conditions of the extremities

12. 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

13. Treatment Goals cont’d Rehabilitation – Stabilize – Increase strength – Maintain flexibility Prevention – Correct habits – Ergonomic modification – Minimize recurrences

14. Distribution of Complaints Duration: 50% 12 wks Onset: 26% significant trauma Shekelle et al. Ann Intern Med 1998

15. 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

16. 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

17. 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

18. 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.

19. 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.

20. 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

21. Myofascial Conditions Tension headache with myogenic trigger Sports injuries Repetitive strain injuries Whiplash and whiplash associated disorder injuries

22. Adverse Affects Short-term muscle soreness or stiffness Rib fracture TIA/dissection

23. 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

24. 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

25. Benefits of Collaborative Care Continuity of care Timely assessment, treatment and reporting Network with other providers Patient satisfaction