Contemporary Chiropractic Care Getting the modern the message across? Dave Newell PhD FRCC (Hon) Director of Research, AECC University College Senior Research Fellow, Faculty of Medicine, University of Southampton
The Problem
The turning tide 1990 2013 Heart disease LBP and Neck Pain
Things might get worse
The Solution
Aren't we doing great?
What does EB contemporary care for LBP look like? ACUTE SMT Advice to remain active Massage Education about their condition Acupuncture NSAIDs CHRONIC Laminectomy (for symptomatic spinal stenosis) SMT Advice to remain active Massage NSAIDs SNRIs Education about their Acupuncture Yoga condition MBSR Interdisciplinary Rehab Exercise Therapy Discectomy (for herniated disc with radiculopathy) Cognitive approaches
Chiropractic Care: Part of the solution?
The mountain has come to Mohamad HISTORICAL CONTEMPORARY Reductive subluxation Holistic patient Centered Single modality Multimodal Isolated practitioner Multidisciplinary Vitalistic explanatory Contextual factor explanatory framework framework Technique and biomechanical Therapeutic alliance and centric cognitive centric Lesion focused Context focused Anecdotal Routine data collection https://bmcmusculoskeletdisord.biomedcentral.com Engineer Gardener /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 RESEARCH CAPACITY Chiropractic Research Council • There are very few chiropractors on the NHS Provide stepping stones for chiropractic • 5 year (2 days per week) Senior graduates to pursue research careers payroll or seeing NHS patients referred from Research Fellow Internships Primary Care. • Two fully funded PhDs program at MRes • Of those that do interact they are normally Primary Care and Population Sciences in PhDs the Faculty of Medicine in the University through individual professional relationships Provide clinical data collections capacity in the of Southampton with GP practices profession Care Response PBRN
Demand: The other side of the supply equation Triage and Treat Practitioner Model Extended Scope Practitioner Model ALL MSK 3,000: GP Chiropractic Practice • Orthopaedic profession • Imaging 50,000 • Conservativ Private patients <10% of e care General appropriate population Practitioners Triage NHS patients: MSK around 1:5 visits: 340 and Treat/ million visits in 2016 ESP
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 LBP LBP • SUSS Data • Health seeking • Cost Primary Care Primary Care • Qualitative • GPs Patient Journey • ESPs • Chiropractors • Patients ESP Triage • CCGs? • Triage • Patient experience Questionnaire • Description of referral and destination • AQP Community based chiropractic care (AQP) • Care Response (MSK HQ, PGIC, Patient satisfaction, Expectation)
Models of Care: Existing Model 2: PHD 2 2 0 Care • Orthopaedic • Treatment by Physiotherapist Measure GP Practice 1. Outcomes LBP 2. Patient experience 3. Costs 4. Health care seeking Triage by Treatment by Chiropractor Chiropractor (Includes SBT) PATIENT CHIROPRACTOR FUNDED FUNDED 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 once, 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.
Perceived Meaning Practitioner-patient dynamic Non conscious neurology Psychology What is Chiropractic Manual Care? Exercise/Rehabilitation • Chiropractic is a profession NOT a treatment • The care that chiropractors deliver is ideally Lifestyle advice/support tailored to the individual patient and includes multiple elements that make up a therapeutic envelope Conscious Neurology • Chiropractic care is a skillfully constructed therapeutic envelope of multiple modalities, woven together with language, stories, Chiropractic context and good listening . Care
Contemporary Chiropractic CARe Historical Paradigm Contemporary Paradigm 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.
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?
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