Submitted by Prof Michael T Haneline DC, MPH, currently is a Professor and Head of Chiropractic at the International Medical University in Kuala Lumpur Malaysia [1]
A trend that has arisen in recent years is a shift toward healthcare that is more consumer driven; i.e. more and more patients are choosing the types of healthcare that they think is best for them, rather than waiting for referrals from their primary care providers. This trend has been beneficial to chiropractors because more patients with the types of conditions most often treated by chiropractors are now seeking out chiropractic care on their own. This trend will likely continue as people increasingly obtain health information from the Internet… information that often points toward the benefits of alternative forms of healthcare, including chiropractic.
Another development that has been favourable to chiropractic is the positive comments about chiropractic that have been presented in recent clinical guidelines. For instance, in 2009 the National Institute for Health and Clinical Excellence in the UK produced guidelines on the best forms of treatment for lower back pain which advised that “…a course of manual therapy, including spinal manipulation…” should be considered.[2]. The vast majority of spinal manipulation (a.k.a., adjustment) is performed by chiropractors and it is their primary therapeutic intervention. Also, in 2007 a joint clinical practice guideline from the American College of Physicians and the American Pain Society that was published in the Annals of Internal Medicine [3] reported that “…clinicians should consider the addition of a non pharmacologic therapy with proven benefits for acute low back pain, spinal manipulation.”
Chiropractic patients have historically been the profession’s main proponents. This was made obvious in a survey of 14,000 subscribers of Consumer Reports magazine [4] which asked questions about the various low back pain treatment methods. The article, which was reported in the magazine’s May 2009 issue, indicated that chiropractic care was the top-rated treatment for back pain sufferers. Chiropractors also received the highest “satisfaction with care” ratings; higher than those given to medical doctors, physical therapists and acupuncturists.
Another aspect of chiropractic care that has been confirmed in a number of studies is that chiropractic care is cost effective. A 2002 study carried out in Florida determined that chiropractic care was more cost-effective than standard medical care in the management of low back pain patients who were injured at work. [5]Another study that compared annual healthcare costs between health plan members with and without chiropractic coverage showed that those with chiropractic coverage had lower overall annual healthcare costs. [6] The results of these studies and others like them should result in growing utilization of chiropractic services by employers and insurers.
Research has validated chiropractic care in the management of low back pain [7] and there is mounting evidence that it is effective for a variety of other neuromusculoskeletal conditions as well (e.g., neck pain and headache) [8],[9] Furthermore, many chiropractors advocate wellness care where satisfied patients return for maintenance or wellness visits, even without obvious symptoms. Some chiropractors also offer advice to their patients about preventative health matters (e.g., proper nutrition, increased physical activity, and avoiding harmful behaviours). These factors, together with high levels of patient satisfaction, should advance the profession and increase patient exposure. It is expected that chiropractic should continue its steady growth in the numbers of patients served as well as the numbers of practicing chiropractors, especially when one considers the developing markets throughout the world, such as in Southeast Asia.
1. MULTI-DISCIPLINARY PRACTICE
A multi-disciplinary centre is a common business model used in the healthcare industry to allow practitioners to create and enhance their value to the community. For the chiropractor there are three main avenues of expansion into multi-disciplinary practice. They are working with:
- Medical professionals such as General practitioners/ Family physicians and/ or Medical specialists, for example Orthopaedic surgeons, and Neurologists etc
- Complementary and Alternative health practitioners, such as Naturopath, Homeopath, Massage therapist, etc or
- Allied professionals such as Pilates Instructors, Fitness leaders and Yoga instructors. A sample of different multi-disciplinary centres from around the world is outlined below.
Providing Chiropractic care to patients that otherwise may not have been offered it as part of their treatment protocol is one big advantage of multi-disciplinary practices for both patients and chiropractors. Wittman’s article[10]discusses one approach to utilising chiropractic care for patients in a multi-discipline setting.
This paper presents a case of a child with Prader-Willi syndrome and the observed improvement in the degree of scoliosis, immune function, and behaviour documented during the course of her treatment. The case involves a 7-year-old girl with a 15° lumbar levoscoliosis and diagnosis of Prader-Willi syndrome under treatment at the Kentuckiana Children’s Center.
The authors note that “the treatment plan consisted of chiropractic adjustments, craniosacral therapy, movement therapy, and nutritional therapy. Over the course of treatment, her muscle strength, tone, and motor activity increased. She improved in coordination of gait and balance. Over the course of 3 years, her scoliosis decreased to 4° to 5°. Improvements in immune function and a reduction in anxiety type behaviours were documented by the parents and doctor of chiropractic over the course of 5 years.” [11][12]
2. MULTI-DISCIPLINARY CENTRES
For almost a century, chiropractors have worked hard to expand the acceptance and understanding of the profession’s healing philosophies. Through a variety of means beyond the clinic-developing a referral system with the medical profession, volunteering with high school athletic programs, creating affiliations with civic associations, participating in health fairs, and marketing to the general public-they have spread the word deeper into public awareness. For some chiropractors, developing a multidisciplinary practice becomes the next logical step. They believe that aligning themselves with providers of other health care specialties-ranging from acupuncture, nutrition, and psychology to physical therapy, anaesthesiology, and internal medicine-is the best means to extend the philosophy.
There are many centers throughout the world that are multi-disciplinary in nature. A sample of different clinics from the USA, Canada and the United Kingdom is outlined here:
1) USA
Papa Chiropractic Jupiter West Medical Center Physical Therapy, Florida
A multi-disciplinary center as well as a chiropractic office.[13]
2) Canada
Alliance Healthcare, Ontario
A multidisciplinary health centre that includes Chiropractic, Paediatrics, Pre and Post Natal care, Physiotherapy, Massage, Chiropody-Foot Specialists, Homeopathy, Acupuncture, Nutrition, Weight Loss, Allergy testing, Reflexology, Reiki and more with a mission to serve the people of our community with a host of services.[14]
The Electra health Floor Inc, Vancouver
The Healthcare and multi-disciplinary practitioners under one roof.[15]
Elgin Chiropractic and Multi-disciplinary Clinic, British Columbia
Chiropractors Dr. Robin Van Der Mark, Dr. Mark Slater and Dr. Tanice Morton use a multi-disciplinary approach to health care. A team of health care practitioners is available at Elgin Chiropractic that helps to ensure that each patient receives appropriate, quality.[16]
3) UK
Fairford Therapy Centre
A multi-disciplinary clinic, offering a variety of treatments under one roof including Acupuncture, Osteopathy, Physiotherapy, McTimoney Chiropractic, Sport & Remedial Massage, Pilates, Hypnotherapy and Counseling.[17]
3. SPECIALISATION OF CHIROPRACTIC INTO FIELDS OF STUDY AND PRACTICE
I. Sports
Sports chiropractic is also known as chiropractic sports sciences/medicine. The focus of sports chiropractors is to provide care in the conservative management, rehabilitation and performance optimization of neuromusculoskeletal system for athletes and to participate in a multi-disciplinary sports injury care environment.
Sports chiropractic achieves this focus through the application of a multimodal treatment approach that includes one or more of the following:
- manipulation
- mobilisation
- soft tissue therapies
- electrotherapy
- rehabilitation and other movement/exercise therapies
- nutritional advice
- strapping and bracing and
- other related approaches
These approaches are applied to injury management in the form of acute, subacute and chronic injury as well as in the prevention of injury and the optimisation of athletic performance through the pursuit of the highest efficiency in neuromusculoskeletal functioning.
A Sports Chiropractor may possess additional qualifications specific to sport. Those chiropractors who have pursued additional study have assimilated a large body of clinical information specific to the special needs of those who participate in sport.
Sports chiropractic is growing rapidly nationally and internationally and is well established at many world level sporting events, such as the Olympic Games and the World Games. The Federation of International Chiropractic Sport (FICS) is the peak, international sports chiropractic body and plays a dominant role in promoting sports chiropractic throughout the world. FICS is made up of many national sports chiropractic councils. These include sports chiropractic councils from Australia, The United States, The United Kingdom, South Africa, New Zealand, Switzerland, Japan, Russia, Italy, Germany, and many others.[18]
A paper prepared by Robert Thomle and Robert Ziegler[19] concluded that the trend towards chiropractic in sports care has been shown to be valid. It is hoped that more definitive studies in the area of nutrition, biomechanics, and injury rehabilitation will be pursued to heighten awareness of chiropractic in the sports care arena. Because of the increasing world-wide interest in sports and fitness, no matter what your age or level of athletic achievement, the opportunity to finally see the role of chiropractic in sports care is at hand.
II. Paediatrics
There have been a number of criticisms of the chiropractic profession in general and a few practitioners in particular relating to treatment of children. Some reviews, like the New Zealand report, have opposed chiropractic care of children on the grounds that it is “useless at best and potentially harmful”.[20] However, the International Chiropractic Pediatric Association (ICPA) has initiated a groundbreaking study on the safety and effectiveness of chiropractic care for children. The preliminary results are outstanding and show that chiropractic care is safe for children. Perhaps even more significant is that parents have reported three unexpected improvements with their children’s care:
- Improved sleeping
- Improved behavior and attitude
- Improved immune system function[21]
Chiropractors wishing to further their knowledge in the field of paediatrics have a number of options for study. Within the USA, they may undertake the Diplomate in Chiropractic Paediatrics program offered by the International Chiropractic Paediatric Association (ICPA). The program is affiliated with numerous Chiropractic Colleges in America and the Institut Franco-Europeen de Chiropratique, of France. In the United Kingdom and Australia, the Chiropractic faculties of the Universities teaching Chiropractic also offer Master degree programs, specializing in Paediatrics. The option to do a Master or Doctorate in Research in Chiropractic Paediatrics is also available at some institutions.[22][23][24][25][26]
III. Neurology
There are about 400 board-certified chiropractic neurologists in the world. In the USA, if a chiropractor wants to become a licensed chiropractic neurologist, he must complete an additional 3-year based course of study in neurology, including coursework, residency-based clinical training and having approved the certification examination administered by the American Chiropractic Neurology Board.
Both chiropractic neurologists and medical neurologists diagnose and treat a wide range of nervous system conditions. The main difference between them is that the therapies prescribed by the chiropractic neurologist do not include drugs or surgery. In addition, chiropractic neurologists could also provide counselling about diagnostic and appropriate care. They treat different movement disorders, such as dystonia (painful involuntary muscle contractions), strokes, hemispheric brain lesions, and radiculopathy or “pinched nerve.” [27]
IV. Orthopaedics
A Chiropractic Orthopaedist is a Doctor of Chiropractic who has undertaken extensive post-doctoral and/or graduate level study in non-surgical orthopaedics. To become a Chiropractic orthopaedist the Chiropractor must pass the specialty board certification examination. Upon successful completion of the examinations, the chiropractor will gain Diplomate status, meaning they are now board certified. Within the field of Chiropractic Orthopaedics there are two autonomous certification boards. They are the Academy of Chiropractic Orthopedists (ACO) and the American Board of Chiropractic Orthopedists (ABCO). Specialists will thus carry the Diplomate designation as DACO or DABCO.
After the successful completion of the examinations and upon gaining Diplomate status, the Chiropractor can become a Fellow of the Academy of Chiropractic Orthopedists (FACO).
In America there is currently one body concerned with Chiropractic orthopaedics, namely the American College of Chiropractic Orthopedists (ACCO). A recent development is the Academy of Chiropractic Orthopedists working with the Chiropractic colleges to support a Master of Science degree in Clinical Orthopedics. This course is scheduled to be offered in late 2010.
The Council on Chiropractic Orthopedics, which is a part of the American Chiropractic Association, specifies the following definition of Chiropractic Orthopedics.
“Chiropractic Orthopedics is defined as that branch of chiropractic medicine that includes the continued acquisition of knowledge relative to both normal functions and diseases of the human body as they relate to the bones, joints, capsules, discs, muscles, ligaments, tendons, their complete neurological components, referred organ systems and contiguous tissues; AND the development and perfection of skills relative to health maintenance when such exists and when not, the investigation, historical review, physical detection, correlative diagnosis development and complete management of any disorder within the bounds defined herein; AND the delivery of the combined knowledge and skill on a primary basis to patients who both need and desire this service to the eventual outcome of remission, whenever resolution is not readily achievable.” . [28]
For further information refer to the following organizations:
Academy of Chiropractic Orthopedists (ACO) [29]
American Board of Chiropractic Orthopedists (ABCO) [30]
American College of Chiropractic Orthopedists (ACCO) [31]
V. Radiology
To become a chiropractic radiologist the chiropractic physician must undergo a highly competitive process which involves extensive post-graduate training in radiology and other advanced imaging techniques through years of residency and training. The student must first finish the four years of chiropractic education and obtain the required degree from chiropractic college. Then, upon graduation, the chiropractic physician must enrol in any chiropractic radiology residencies (three year) that are available at national and international levels.
After completing the residency, the chiropractic physician is eligible to take the Board examination in order to be certified. The exam has two parts and covers all aspects of diagnostic imaging such as bone, neuroradiology, gastro-intestinal, genitourinary and musculoskeletal topics,among others. In the USA, after passing the Board examination the chiropractic physician will have a diplomate status with the American Chiropractic Board of Radiology (DACBR) and will be a member of the American Chiropractic College of Radiology. There are approximately 60,000 licensed chiropractic physicians in the U.S., and up to 2008 less than 300 have successfully completed this certification process.
But the training does not end with the Board certification, the chiropractic radiologist generally receives additional training – in musculoskeletal and/or neuroradiology advanced imaging – acquired through programs provided by some of the most prestigious medical institutions and organizations. Furthermore, the American Chiropractic Board of Radiology in order to maintain advanced imaging certification requires additional hours on an annual basis.
Chiropractic radiologists can apply their knowledge adopting different roles in different areas of expertise. Almost all chiropractic radiologists provide some form of diagnostic imaging consulting services which includes interpretation of x-ray film, MRI and CT scans for chiropractic and medical clinics as well as diagnostic imaging centers. Some will serve in an academic or administrative role such as teaching and/or research at a chiropractic or medical school. Many will provide postgraduate level lectures through various venues. Another important role for the chiropractic radiologist includes providing expert testimony or consultation regarding legal matters such as medical malpractice, personal injury, workers’ compensation, merit determination and insurance claim disputes.[32], [33]
VI. Nutrition
Specialisation into and study of Nutrition is a common path for Chiropractors to pursue to enhance their clinical skills. According to Press [34] “Chiropractors qualified in the field of nutrition are able to give pertinent advice on vitamin supplementation, dietary intakes, environmental toxicities, homeostasis, and biomechanical reactions of bodily systems.”
Chiropractors interested in studying Nutrition can do so via the Chiropractic colleges or through the various nutrition boards. The American Chiropractic Association has a Council on Nutrition and also a separate Clinical Nutrition board [35]. In order to become a Diplomate of the American Chiropractic Board of Nutrition (DACBN) a Chiropractor has to complete at least three (300) hours of postgraduate study in nutrition sponsored by a college or other authorised agency.
The Chiropractic Board of Clinical Nutrition (CBCN) is an autonomous body under the American Chiropractic Association.[36] It serves to provide teaching, examination and certification in the field of nutrition. Chiropractors that complete the certification under the CBCN are eligible to attain Diplomate status and use the DCBCN suffix.
Integrative Approach
Chiropractors already have a background in science which should serve as a base of knowledge to understand how nutrition affects the body. The average person knows very little about nutrition. They know the basic facts that fatty foods are bad or to avoid too much sugar, chiropractors can do a great deal in educating and motivating their patients. That is why some chiropractors include nutrition therapy as part of their practice after having assessed first their patients’ history, physical examination, current diet and lifestyle.
Many patients are looking to chiropractors who are helping them manage specific health problems through an integrative approach that encompasses nutrition. Integrative health care focuses on how biochemical individuality, metabolic balance, ecological context, genetic predisposition, lifestyle patterns and other factors have the potential to strongly influence human physiology and the push pull dynamics of health and disease. After the evaluation and testing is completed, qualified chiropractors will be able to make recommendations on what foods to eat, what foods to eliminate, how to remove toxins, possible supplements for specific needs and exercise.
VII. Therapeutics and Rehabilitation
Chiropractors qualified in the field of rehabilitation are typically involved in the diagnosis, treatment and management of more complex and difficult cases. Chronic unremitting lower back pain sufferers are often the patients most in need of these services. In addition to chiropractic adjustment and other modalities, the rehabilitation specialist will create a customised exercise plan for the patient. The customised rehabilitation program will often include spinal stabilisation exercises, core muscle exercise, sensory motor stimulation and other methods of challenging the patients’ proprioceptive (movement) system. The purpose of these exercises is to recondition the body to regain normal or a near normal function.
Rehabilitation experts normally undertake post-graduate certificate, diplomas or degrees to develop these skills. Some practitioners will undertake study to gain a Masters degree or PhD by research qualification available through certain institutions.
VIII. Animal chiropractic
Animal Chiropractic is a growing field with many Chiropractors now actively engaged in this practice and animal owners seeking out properly trained chiropractors. Historically many chiropractors gave adjustment to their own pets (dogs especially) to keep them mobile and active.
Animal chiropractic is a specialised field with Chiropractors needing to undertake graduate certificates or post-graduate degrees in order to treat animals. One major area of interest is Equine chiropractic. Horse racing, eventing and polo are tough on a horses’ physical structure and many owners now recognise the benefits of chiropractic care for their horses. The Animal chiropractor will typically work in concert with a veterinary doctor to manage the animals welfare.
Further information about animal chiropractic can be found at:
American Veterinary Chiropractic Association (AVCA) [37]
College of Animal Chiropractic [38]
The Wonders of Animal Chiropractic [39]
Canadian Animal Chiropractic Certification Program [40]
Australian Veterinary Chiropractic Association. [41]
International Veterinary Chiropractic Association (IVCA) [42]
References
- Haneline MT. Current trends in chiropractic practice.2010 Feb.
- National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://guidance.nice.org.uk/CG88.
- Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007 Oct 2;147 (7):478-91.
- ConsumerReports.org. Relief for aching backs: hands-on therapies were top-rated by 14,000 consumers [Online]. 2009 May [cited 2010 Feb]; Available from: URL:http://www.consumerreports.org
- Folsom, Byron L, Robert W, Holloway. Chiropractic care of Florida’s workers’ compensation claimants: access, costs, and administrative outcome trends from 1994 to 1999. Topics in Clinical Chiropractic; 2009.p.33-53.vol 9(4)
- Antonio PL, Metz DR, Nelson CF, Ray S, Chernicoff HO, Nicholas A. Comparative analysis of individuals with and without chiropractic coverage Archives of Internal Medicine; 2004 Oct 11.p.164.
- Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-back pain. Cochrane Database of Systematic Reviews; 2004. Issue 1. Art.No.:CD000447.
- Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJJ, Bouter LM. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database of Systematic Reviews; 2004, Issue 3. Art. No.: CD001878.
- Gross, Anita R, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Cochrane Cervical Review Group; 2004 July 15.p.1541-1548.vol 29(14).
- Wittman RA, Vallone SA. Inclusion of chiropractic care in multidisciplinary management of a child with Prader-Willi syndrome: a case report. J Chiropr Med [serial online] 2009 Dec [cited 2010 Feb]; 8(4):193-199. Available from: URL:http://www.ncbi.nlm.nih.gov
- The Multidisciplinary Practice: The Patient Sees the Best of Both Worlds. [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.chiroweb.com
- Journal of American Chiropractic Association (JACA). [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.acatoday.org/
- Papa chiropractic Jupiter West Medical Center Physical Therapy [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://www.jwmcpt.com/default.asp
- Alliance Health Centre [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://www.alliancehealthcare.ca/
- The Electra Health Floor Inc. [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://www.electrahealthfloor.com/
- Elgin Chiropractic and Multi-disciplinary Clinic [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://www3.telus.net
- Fairford Therapy Centre [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://www.fairfordtherapycentre.co.uk/
- Chiropractors’ Association of Australia. What is sports chiropractic [Online].2010 [cited 2010 Feb]. Available from: URL:http://chiropractors.asn.au
- Thomle R, Ziegler R. Is there a trend toward chiropractic in sports care?. Dynamic Chiropractic [serial online] 1991 June 21 [cited 2010 Feb]; 9(13). Available from: URL:http://www.chiroweb.com
- Rupert RL. Chiropractic paediatrics. Dynamic Chiropractic [serial online] 1994 June 17 [cited 2010 Feb]; 12(13). Available from: URL:http://www.chiroweb.com/mpacms/dc/
- International Chiropractic Pediatrics Association. Children’s chiropractic safety research [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://icpa4kids.org
- Adjusting the pediatric spine. [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.chiro.org
- Chiropractic care for children. [online]. 2010 [cited 2010 Feb]; Available from: URL: http://archpedi.ama-assn.org
- Children use alternative therapies. [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.chiroweb.com/mpacms/dc/article.php?id=37001
- Pediatric chiropractic: Our growth of family wellness care. 2010. [cited 2010 Feb]; Available from: URL: http://www.dynamicchiropractic.com
- Chiropractic — Is It Safe for Children?. [online] 2010. [cited 2010 feb]; Available from: URL:http://www.chiroweb.com
- Azzolino Chiropractic Inc. What is a chiropractic neurologist [Online] 2010 [cited 2010 Feb]; Available from: URL:http://www.azzolino.com/faqs.html
- Council on Chiropractic Orthopedics. Improved sleeping [Online]. 2010 [cited 2010 Feb]; Available from: URL:www.ccodc.org
- Academy of Chiropractic Orthopedists (ACO) [online]. 2010 [cited 2010 Feb]; Available from: URL: www.dcorthoacademy.com
- American Board of Chiropractic Orthopedists (ABCO) [online]. 2010 [cited 2010 Feb]; Available from: URL: http://abconet.org
- American College of Chiropractic Orthopedists (ACCO) [online]. 2010 [cited 2010 Feb]; Available from: URL: www.accoweb.org/index.html
- Diagnostic Imaging Consultants. Radiologist [Online]. 2010 [cited 2010 Feb]; Available from: URL:http://www.dcradiology.com/article-sandman.html
- American Chiropractic College of Radiology [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.accr.org/
- Press SJ. The role of the chiropractic physicians in the sports medical team. Am Chiropractor; 1987 August. p. 31-36.
- ACA Council on Nutrition [online]. 2010 [cited 2010 Feb]; Available from: URL:http://www.councilonnutrition.com
- Chiropractic Board of Clinical Nutrition (CBCN). 2010 [cited 2010 Feb}; Available from: URL: http://www.cbcn.us/
- American Veterinary Chiropractic Association (AVCA) [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.animalchiropractic.org/
- College of Animal Chiropractic [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.animalchiro.com/
- The Wonders of Animal Chiropractic [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.chiroweb.com
- Canadian Animal Chiropractic Certification Program [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.veterinarychiropractic.ca/
- Australian Veterinary Chiropractic Association. [Online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.avca.com.au/
- International Veterinary Chiropractic Association (IVCA) [online]. 2010 [cited 2010 Feb]; Available from: URL: http://www.ivca.de
