Contemporary Chiropractic Care Getting the modern the message - - PowerPoint PPT Presentation

Dave Newell PhD FRCC (Hon)

Director of Research, AECC University College Senior Research Fellow, Faculty of Medicine, University of Southampton

Contemporary Chiropractic Care

Getting the modern the message across?

The Problem

The turning tide

Heart disease LBP and Neck Pain

1990 2013

Things might get worse

The Solution

Aren't we doing great?

What does EB contemporary care for LBP look like?

CHRONIC

Advice to remain active Education about their condition Advice to remain active Education about their condition Exercise Therapy

ACUTE

Cognitive approaches

SMT SMT Massage Interdisciplinary Rehab MBSR Yoga Acupuncture Massage Acupuncture NSAIDs SNRIs NSAIDs Discectomy (for herniated disc with radiculopathy) Laminectomy (for symptomatic spinal stenosis)

Chiropractic Care: Part of the solution?

The mountain has come to Mohamad

HISTORICAL CONTEMPORARY Reductive subluxation Holistic patient Centered Single modality Isolated practitioner Multimodal Multidisciplinary Vitalistic explanatory framework Contextual factor explanatory framework Technique and biomechanical centric Therapeutic alliance and cognitive centric Lesion focused Context focused Anecdotal Routine data collection Engineer Gardener

https://bmcmusculoskeletdisord.biomedcentral.com /articles/10.1186/s12891-018-1943-8

Can the UK chiropractic profession contribute in any meaningful way to wider MSK healthcare delivery?

UK chiropractic profession: Research in healthcare delivery impact

• Over the last 20 years or so there has been a

concerted effort to increase research output and capacity within the profession

• However this is patchy worldwide
• Denmark, Canada and the US have

progressed significantly with Denmark in particular generating world leading MSK research

• The UK has predominantly relied on a few

individuals within academic chiropractic programs to generate what research there is which although hugely commendable has been small scale with limited impact.

Some ambitious goals

• CHIROPRACTIC PARTNERSHIP WITH NHS
• There are very few chiropractors on the NHS

payroll or seeing NHS patients referred from Primary Care.

• Of those that do interact they are normally

through individual professional relationships with GP practices RESEARCH CAPACITY Provide stepping stones for chiropractic graduates to pursue research careers Internships MRes PhDs Provide clinical data collections capacity in the profession Care Response PBRN Chiropractic Research Council

• 5 year (2 days per week) Senior

Research Fellow

• Two fully funded PhDs program at

Primary Care and Population Sciences in the Faculty of Medicine in the University

• f Southampton

Demand: The other side of the supply equation

3,000: Chiropractic profession

Private patients <10% of appropriate population

50,000 General Practitioners

NHS patients: MSK around 1:5 visits: 340 million visits in 2016

Triage and Treat Practitioner Model Extended Scope Practitioner Model ALL MSK GP Practice Triage and Treat/ ESP

• Orthopaedic
• Imaging
• Conservativ

e care

Chiropractic care and the NHS

• The vast majority of chiropractors work within

the independent sector

• The number of chiropractors working in or

alongside the NHS is extremely limited. This has been restricted to a handful of chiropractors involved in AQP provision and with bespoke working relationships with GP practices

• Any development therefore in achieving better

access will require exploration of potential models of interface with the NHS and their efficacy, utility, cost and patient experience

• Models with other allied health professions

have already explored this type of service delivery and we will hopefully use similar approaches to measurement

• The triage and treat national low back pain

pathway is already being implemented and data gathered

http://tvscn.nhs.uk/wp-content/uploads/2017/11/Musculoskeletal-Service-improvements.pdf

Models of Care: Existing Model 1:PhD 1

• SUSS Data
• Health seeking
• Cost
• Qualitative
• GPs
• ESPs
• Chiropractors
• Patients
• CCGs?
• Triage
• Patient experience Questionnaire
• Description of referral and destination
• AQP
• Care Response (MSK HQ, PGIC,

Patient satisfaction, Expectation) Community based chiropractic care (AQP) ESP Triage Primary Care

Primary Care

Patient Journey LBP LBP

Models of Care: Existing Model 2: PHD 2

20 Care

• Orthopaedic
• Treatment by

Physiotherapist

Treatment by Chiropractor

PATIENT FUNDED

Triage by Chiropractor (Includes SBT)

CHIROPRACTOR FUNDED LBP

GP Practice

Measure

• 1. Outcomes
• 2. Patient experience
• 3. Costs
• 4. Health care seeking

Patient choice wait for Physiotherapy Patient choice see chiropractor within 24 hours

Trialling a model of Chiropractic care delivery in the community

• So at the risk of being in this situation
• Develop a model that provides a route for

suitable MSK patients to chiropractic care in the community as provided by appropriately upskilled chiropractors (Triage and Treat skills as defined by National Back Pain Pathway)

• Implement a feasibility study of a trial

against usual care in a CCG willing to participate (Right Care support, Health Service and Delivery Research)

• Seek funding for full trial from Research for

Patient Benefit (RFPB)

Chiropractic Care: Contemporary descriptions

The problem of identity: Finding descriptive analogies

• The Carpenter
• The identity of a carpenter skill is in the application of tools

not the tool owned

• No one gets upset when a carpenter has not used enough

‘plane’

• “Call yourself carpenter I never saw you use the chisel
• nce, you might as well call yourself a lumberjack for all the

sawing you do”

• How ridiculous
• The Gardener
• You are not an engineer
• You do not find broken cogs and fix them
• You create therapeutic landscapes through which you walk

with the patient on their journey to recovery of management.

• You work with nature not inanimate mechanism
• Each garden may be different and your route through is

slower or faster depending on the patient.

What is Chiropractic Care?

• Chiropractic is a profession NOT a treatment
• The care that chiropractors deliver is ideally

tailored to the individual patient and includes multiple elements that make up a therapeutic envelope

• Chiropractic care is a skillfully

constructed therapeutic envelope

• f multiple modalities, woven

together with language, stories, context and good listening.

Manual Exercise/Rehabilitation Non conscious neurology Lifestyle advice/support Chiropractic Care Perceived Meaning Psychology Conscious Neurology Practitioner-patient dynamic

O’Sullivan PB, Caneiro JP, O’Keeffe M, et al. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther. 2018;98:408–423.

Contemporary Chiropractic CARe

Historical Paradigm Contemporary Paradigm

Getting the message across?

1. The burden of healthcare resources spent for MSK conditions is huge, increasing and guidelines increasingly support the sorts of conservative approach that the chiropractors deliver. 2. Modern chiropractic education is focused on contemporary training to identify and manage the most common MSK conditions 3. The package of care includes multiple modalities wrapped in powerful context and skilfully delivered to individual patients in a patient centred focus 4. There is solid evidence to support it as one of the best approaches to LBP, NP and SP, conditions the vast majority of patients come to see chiropractors for. 5. Are we getting this concise and contemporary message across?

THANK YOU FOR LISTENING