By Dr. Shawn Thistle
Spring 2014

The Current Situation

Spine-related disorders (SRDs) – encompassing low back pain, neck pain, some types of headaches and radiculopathy – are extremely common and often recurring, potentially debilitating conditions that affect just about every individual at some point in the lifespan (2). In fact, low back pain (LBP) is the second most common symptomatic reason patients consult a family doctor (3) and is now the leading cause of 'days with disability' worldwide (neck pain is #4 on this list!) (4).

SRDs place a massive burden on society, industry and healthcare systems around the globe. Despite a staggering rise in expenditure on advanced diagnostic imaging, specialist visits, medications and other interventions, the magnitude of improvement in patient outcomes has not been commensurate. In fact, disability resulting from SRDs is rising (6)!
There is a wide variety of practitioners with diverse educational backgrounds caring for patients with SRDs. Leading experts have referred to this as a 'supermarket approach' to SRD care (5), where vulnerable patients are left to navigate the wide range of treatment options on their own. Unfortunately, marketing, salesmanship and practitioner-centred financial incentive often trump science, the patients' best interest (and even logic) in the management decision-making process, leading to inappropriate diagnostic tests, ineffective treatment and increased risk for long-term disability and pain.

In light of the massive and growing impact of SRDs, there is a pressing need for the establishment and development of a primary spine care provider (PSCP) – a clinical specialty with advanced training in spine care, in depth awareness of the multifactorial nature of SRDs, and ability to assist in patient-centred, rational clinical decision-making (2). Health care systems desperately need appropriately trained, skilled clinicians to fill the role of PSCP for the diagnosis and non-surgical management of SRDs...a "primary care physician for the spine", if you will. This role and delivery model has, of course, worked very well in dentistry, podiatry, optometry and numerous medical specialties (1).

The PSCP Challenge

On the surface, the proposed role of PSCP may seem simple, yet to appropriately fulfill this responsibility, a clinician must have (1, 2):

• Astute diagnostic capability, including the ability to differentiate systemic/inflammatory disease from degenerative processes as well as other causes of spinal pain
• Specialized training in SRDs and numerous forms of spine care (including manual therapy, medications, percutaneous injection options, exercise and rehabilitation etc.)
• Familiarity with surgical interventions and their evidence-based indications and implications
• Intimate awareness of the abilities and limitations of other spine care providers and specialists who can provide necessary complimentary interventions (both surgical and non-surgical)
• Evidence-based, scientifically defensible, cost-effective, clinically-relevant, collaborative, patient-centred care practices for SRDs
• Appreciation for minimalism and quality of care to minimize excess spending and the development of treatment dependency
• Understanding of the unique aspects of work-related and motor vehicle collisions-related SRDs
• Broad perspective on the public health correlations with SRDs including smoking, obesity, lack of exercise, mental health disorders
• Ability to screen for psychosocial morbidity and professionally communicate with appropriate providers of care for these conditions and other aspects of biopsychosocial rehabilitation
• An understanding of pain and chronicity from a biological and clinical research perspective, with working knowledge of the clinical implications for patient communication, establishing realistic expectations and approaching case management
• Ability to coordinate care among numerous practitioners and follow patients for a prolonged period of time if necessary

This is likely not a comprehensive list and is in no particular order, but represents a tall order for an individual clinician as it stands! In fact, the true solution to this problem likely exists in a coordinated, team-based approach. But, every team needs a leader! The PSCP would function as such a leader and represent the point of first clinical contact for patients with SRDs, also functioning as a resource for traditional primary care providers (family practice physicians, general internal medicine physicians, pediatric, obstetrical/ gynecological physicians, etc.) to refer patients who present with SRDs.

There is currently no single discipline or professional group that fills this important role. Further, traditional primary care givers (PCGs – family physicians) are not well trained in the differential diagnosis and management of musculoskeletal disorders, including SRDs. This is likely due to the heavy (and necessary) emphasis on internal diseases in medical school and in primary care residency programs. Family doctors have lots of other things to worry about to be sure! There is a strong body of evidence that published clinical guidelines are not well-implemented in practice (8, 9), and there is even evidence that even those PCGs professing to have a special interest in SRDs tend to have anachronistic beliefs about best practices for assessing and managing these disorders (10).

Benefits of Establishing a PSCP

Although it would require systematic research to properly evaluate the benefits of this initiative, it is reasonable that the establishment and implementation of a PSCP role would offer the following benefits:

• Faster patient recovery via timely implementation of patient-centred, evidence-informed interventions, active treatment plans, appropriate triage and patient education/empowerment
• Cost containment (even savings), primarily from avoiding unnecessary treatments and imaging/diagnostic tests
• Avoidance of iatrogenic disability via consistent communication and avoiding unnecessary medicalization of imaging findings with questionable significance
• Increased productivity through patient activation and targeted return to work programs
• Higher patient satisfaction and shared decision making (an important and oft-ignored pillar of evidence-based care!)
• Unburdening of family physicians and other primary care contact points as well as ensuring more appropriate and necessary specialist referrals

The Opportunity for Chiropractors

While reading this article, you might be thinking we (chiropractors) are perfectly suited to fill this important role in the health care system. At the very least, we could lead the way in a team-based or multidisciplinary solution. For the most part, I agree with you, but as a collective we must approach this in a reflective, evaluative, logical manner.

Overt reform in our profession would be required in some areas and this is something we cannot take lightly, as there are certainly other professions that would contend and be appropriate for this role. Physiotherapists with a musculoskeletal focus and manual therapy training come to mind as a viable option. For the record, I believe the best answer to this issue may exist in a combined effort between our professions...

Our mere historical interest and attention to the spine alone do not translate into comprehensive expertise in the current healthcare environment – the PSCP is a position we must earn. Unfortunately, we are currently not viewed nor utilized as PSCPs. To illustrate, a 2009 national survey conducted by the Canadian Chiropractic Association revealed that 60% of Canadians recognize that chiropractors treat back pain, and just over 40% regard chiropractors as experts in back pain (7). Further, despite the impact and burden of SRDs, the utilization rate for chiropractors has remained stagnant for years (around 10% according to most datasets).

What currently exists in the field of spinal care is an opportunity our profession must acknowledge and swiftly seize. If we don't, others will, and if we allow this to occur, it is my opinion that we will remain a fringe discipline, destined to continuing fighting amongst ourselves while patients who could benefit from our care suffer. This is a big deal!

A Way Forward for Chiropractic

In a society-wide effort to establish a PSCP and implement an effective primary care approach for SRDs, there are some significant factors we must acknowledge and address:

Education: Currently, educational institutions are not graduating clinicians who meet all requirements for a PSCP. Chiropractic programs certainly check a number of the required boxes, but would have to add additional training in areas such as: basic pain medications, indications and efficacy of various surgical interventions, advanced imaging and diagnostics. Such advanced training may best be implemented in optional programs over and above existing chiropractic education. This is not unreasonable and such programs have been established in some regions (eg. www.primaryspineprovider.com).

Professional Prejudice: It is likely that the best fit for the PSCP role will come from outside the traditional allopathic disciplines. This may be met with significant resistance from some parts of the medical community. Since the solution to SRD-related problems often require some non-traditional thinking, it would be crucial that a competent PSCP be accepted regardless of the degree after his or her name.

Financial Incentives surrounding the 'supermarket approach': Many practitioners (in all disciplines) are seeing high volumes of patients while offering treatments that are of little benefit; they focus on quantity versus quality while ignoring patient outcomes. The establishment of a PSCP would represent a significant shake up in most health care systems – referred to as disruptive innovation (2) – putting some of these practitioners at risk. To me, this is an acceptable and necessary consequence of improving health care delivery. Successful practices can, and do, utilize patient-centred, evidence-informed care!

Resistance from within the chiropractic profession: The philosophical and practice differences among chiropractors are well known to readers (we don't have time to get into this issue here!). Simply put, there are those who feel the role of PSCP would limit our perceived (and actual) expertise to spinal conditions. To this I say – so what?! Since the vast majority of our patients see us for SRDs anyway (most surveys indicate ~90%), this would not be a significant shift in our case load or patient population. In addition, since virtually everyone will suffer a SRD at some point in their lifetime, wouldn't it be beneficial to be THE profession that patients seek for care?

Conclusion

The burden of SRDs is significant and undeniable. Current care patterns are becoming more costly while not improving patient outcomes. We, as evidence-informed chiropractors, are perfectly positioned to play a key role as the PSCP of the future, or at least a critical member of a team approach to this important issue. Taking action NOW can raise our credibility and ensure a successful future for younger practitioners. However, in order for this to come to fruition, we must collectively take action while remaining accountable, collaborative and open-minded.

REFERENCES

1. Erwin MW, Korpela AP, Jones RC. Chiropractors as Primary Spine Care Providers: precedents and essential measures. Journal of the Canadian Chiropractic Association 2013; 57(4): 285-291.
2. Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropractic & Manual Therapies 2011; 19:17.
3. Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS: Patterns and perceptions of care for treatment of back and neck pain: results of a national survey. Spine 2003, 28(3): 292-297, discussion 298.
4. Vos T, Flaxman AD, Naghavi M et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2163–96.
5. Haldeman S, Dagenais S: A supermarket approach to the evidence informed management of chronic low back pain. Spine Journal 2008, 8(1): 1-7.
6. Kosloff TM, Elton D, Shulman SA et al. Conservative Spine Care: Opportunities to Improve the Quality and Value of Care. Population Health Management 2014 (in press).
7. Canadian Chiropractic Association [homepage on the Internet]. Toronto ON: The Association; 2014. 2009 National public opinion survey highlights. Available from: http://www.chiropracticcanada.ca/en-us/members/practice-building/survey-highlights/public-opinion.aspx.
8. Finestone AS, Raveh A, Mirovsky Y et al. Orthopaedists' and family practitioners' knowledge of simple low back pain management. Spine. 2009; 34: 1600–1603.
9. Williams CM, Maher CG, Hancock MJ, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010; 170: 271–277.
10. Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine 2009, 34(11): 1218-1226, discussion 1227.