The 2009 Spinal Model of Care published by the Western Australian Health Department via the Musculoskeletal Health Network would benefit from an update. Best-evidence synthesis and cost-risks-benefits estimations suggest that such guidelines should provide: (1) the early assessment of patients with non-malignant spinal pain (particularly low back) by a musculoskeletal clinician, be it a chiropractor, musculoskeletal physician, osteopath or musculoskeletal physiotherapist with referral within the early stages of the disorder; and (2) the provision of manipulative therapy, where indicated, as a first-line treatment while also providing rehabilitation, health promotion, and contemporary wellness/wellbeing management with the intention of avoiding chronicity. Emerging workforce capacity suggests that early assessment and evidence-based management of non-malignant spinal pain is feasible, leading to better patient outcomes. The authors and the association are hopeful that providing this submission in open access may prove useful for advocates of the chiropractic profession in other jurisdictions.
The importance of addressing spinal pain in the Australian community in a cost effective and clinically appropriate manner is illustrated in a series of studies emerging from the Global Burden of Disease 2010 Project.1 It is well-known that musculoskeletal conditions, such as low back pain, neck pain and arthritis, affect more than 1.7 billion people worldwide and are set to become more prevalent with a growing, ageing, developed world population.2 Australian chiropractors may occupy a pivotal role in the cost effective management of these clinical presentations.
In 2009, the Western Australian Health Department via the Musculoskeletal Health Network, published evidence based guidelines in the form of a model for the management of spinal pain.3 Overall, the key objectives, as reported in this model of care are: (a) devolution of musculoskeletal health services from hospital-based to community-based services (b) a multidisciplinary approach to care; (c) better and early access for patients to assessment and appropriate care; (d) prevention of chronic spinal pain, where possible (e) improvement upon clinical guidelines for best practice and target professional education regarding spinal pain; and (f) dissemination of information to the public and healthcare professionals regarding self-help and evidence-based care. These objectives all resonate strongly with the chiropractic profession.
In 2012 the state of Oregon adopted guidelines for the management of Low Back Pain which recommend spinal manipulation as the only non-pharmacological treatment and further that spinal manipulation be considered as a first tier intervention before medications [including simple analgesia]. CAAWA recognised the implications for Australia and accordingly funded a project tasked to compose a submission the WA Health which echoed the Oregon initiative. The following paper is a synopsis of that submission.
The full submission sets out to provide a synopsis of the most recent research evidence to inform best practice for spinal pain, particularly low back pain, and maps this evidence against the recommendations of emerging musculoskeletal service plans, with a view to building upon the current recommendations in the WA Spinal Pain Model of Care.3 The submission outlines an initial strategy to translate research into practice and enhanced workforce capacity by proposing a consensus-led approach to care provision. The document outlines contemporary evidence on spinal manipulation and presents the benefits of a conservative approach in terms of cost and risk analysis, workforce capacity and community engagement.
Regardless of one’s individual ideological standpoint, one has to concede that spinal pain is by far the most common problem (symptom) encountered in chiropractic practice, particularly low back pain.4 Whether one’s approach to management is subluxation-based, wellness care-based or exclusively that of symptom reduction, the goal for all chiropractors is surely to ‘get patients better’ and keep them better. Another reality is that over 95% of surveyed chiropractors provide patients with the high-velocity, low/controlled-amplitude thrust technique, regardless of whether this is described as an “adjustment”, a “manipulation” or a “technique”.4
With this in mind, a significant opportunity is now unfolding within the mainstream healthcare system in Western Australia where chiropractic can define a concrete role and expand on current practice by offering what most chiropractors do, as indicated previously, without dictating practice or impinging upon professional autonomy. Over the last 10 years or so there has been a paradigm shift within mainstream healthcare related to the treatment and management of musculoskeletal disorders (among others), such as osteoporosis, arthritis, back pain and fibromyalgia.3 This has been driven internationally by, firstly, escalating inflationary costs of care and expensive healthcare technology, to the point where cost-containment is essential, particularly with increasing demand on healthcare services and reduced healthcare budgets.5,6 Secondly, mainstream treatments for many musculoskeletal disorders, particularly chronic problems, have been met with limited success, resulting in a re-think among policy-makers and clinicians. Much of the healthcare discourse and focus has now shifted (back) to health promotion, emphasizing self-help management and disease prevention.7,8
Many of these musculoskeletal disorders, such as spinal pain, are complex and require a care strategy beyond a tablet or injection. Attention needs to be given to not only the most effective, evidence-based management but to other factors, such as poor lifestyle, lack of exercise and patient education.
This submission presents an overview of emerging and existing research evidence in support of manual and manipulative therapy, particularly spinal manipulative therapy (SMT), as a first-line treatment for acute non-malignant spinal pain, with potentially significant cost-savings over usual medical care. This does not mean the authors advocate ignoring usual medical care, but rather the application of judicious medical treatment with the addition of SMT to the care package. Research evidence supports the early referral and assessment of spinal pain patients by an appropriately trained and vetted musculoskeletal clinician, like a chiropractor, musculoskeletal physician, osteopath or musculoskeletal physiotherapist, with a view to offer treatment; facilitate health promotion, rehabilitation and patient education i.e. to apply the right treatment, at the right time, in the right place.9 Early referral and assessment also has potential cost savings by avoiding unnecessary imaging/investigations, hospitalisations, medical procedures and surgery.10 Needless to say, healthcare policy-makers and bureaucrats are very interested due to potential cost savings, which could be as much as a 20% saving on current expenditure for low back pain within mainstream healthcare.5
The CAA (WA), among other professional organisations, is now lobbying to update current Australian clinical guidelines for spinal pain (NHMRC Acute Musculoskeletal Pain Guideline, 2004) and expand on the WA Spinal Pain Model of Care (2009) to incorporate SMT as first-line treatment for non-malignant low back pain and the need for early referral and assessment by an appropriately trained and vetted musculoskeletal clinician. With chiropractors being skilled in primary-care of non-malignant spinal pain (and spinal health), it is only logical to offer their services and participate in the management of spinal pain patients, within a multidisciplinary context. This would also have numerous major advantages for chiropractic: (a) it would define a recognized role for chiropractic within mainstream healthcare without relinquishing professional autonomy, (b) it would expand on chiropractic practice by adding to current practice and creating new employment opportunities, and (c) it could potentially expand on (Australian) Medicare reimbursement for chiropractic services (if the lobby is successful). This would, at least in part, secure the future of an expanding chiropractic profession within a very competitive marketplace.
The Chiropractors Association of Australia (Western Australian Branch) (CAAWA), and other professional organisations like the Australian Physiotherapy Association and Australian Osteopathic Association have been actively involved in key Western Australian Health committees and working groups, and have prepared specific reports, with the objective of lobbying for change.11-13 Encouragingly, efforts have been met with broad agreement, support and enthusiasm by key persons and bodies within WA Health. To date, the above goals of SMT as first-line treatment and early access of patients to musculoskeletal clinicians has not yet been realized, and success is not guaranteed, but progress so far has been very pleasing. This present submission to the Musculoskeletal Health Network of WA has been endorsed by the CAA(WA), The Australian Osteopathic Association and The Manipulative Physiotherapy Association (WA). Subsequent to the submission, the WA Health Department sought expressions of interest from health professionals, key stakeholder organisations, consumers and carers to participate in a Pain Health Working Group. The Pain Health Working Group will facilitate development of an evidence based model of care, or framework, for all persistent pain management within Western Australia, and recommend strategies for implementation. A chiropractor is now a member of this new Pain Health Working Group.14
The Musculoskeletal Health Network (WA), via activities such as the development of the Spinal Pain Model of Care (SPMoC), has already made significant strides in identifying key issues related to spinal pain management and has exposed gaps in future service provision. In particular, a multidisciplinary approach to care of spinal pain delivered at the local community level has been earmarked for improvement in service provision, being confirmed by the outcomes of the WA Musculoskeletal Network Stakeholder Forum Report.15 The emphasis on musculoskeletal health, which includes spinal pain, is also reflected in the newly-launched PainHEALTH website, designed to help consumers with musculoskeletal pain access reliable and usable evidence-based information, with the view to engage with those patients and the broader community.16