BACK Issue 14 MATTERS - Canadian Chiropractic Association · 2017-12-07 · Issue 14 Canadian Chiropractic Association 2017 1. BACK MATTERS. Issue 14. News and Views for Canada’s

Issue 14 | Canadian Chiropractic Association | 2017 1

BACK MATTERS

Issue 14

News and Views for Canada’s Chiropractors

ANDRE DE GRASSE

Special Guest

CCANCT’18

Appearing at the 2018 CCA National Convention & Tradeshow

Canadian Olympic Medal Winner

Issue 14 | Canadian Chiropractic Association | 20172

The Personal refers to The Personal Insurance Company. Certain conditions, limitations and exclusions may apply. The terms and conditions of the coverages described are set out in the insurance policy, which always prevails. Auto Insurance is not available in MB, SK and BC due to government-run plans.

ONE-STOP WATER PROTECTION & DETECTION The Personal offers a range of protection against water damage, with basic and optional coverage to meet your needs.

Protect your property even more with H2O+ Solutions in addition to our home insurance.

YOUR PERSONAL CONNECTION TO HOME AND AUTO GROUP INSURANCE

Above Ground Water Coverage Ground Water Coverage New! Flood Coverage

1

2

3

Follow us for tips on how to prevent water damage.

ALERT Water and freeze detector with smartphone notifications in The Personal App

The right fit.

Protecting your home just got easier.Try our new quoter! thepersonal.com/cca 1-888-476-8737

SAFEGUARD WHAT MATTERS

... WITH HOME INSURANCE FROM THE PERSONAL

1

2

3


COLUMNS

CHECK IT OUT

6 Message from the Chair

8 Message from the CEO

12 Advertising and False Claims: Managing Risks Online

28 Responding to the Opioid Crisis: Changing the Conversation about Pain Management

36 Membership Matters: The 2018 CCA Awards

ISSUE 14

BACK MATTERS

10 Business Profile: Building Your Practice in a Small City

17 Champion Profile: Morneau Shepell®

26 Pain Knows No Language: Chiropractic Care in the Dominican Republic

30 Join the Excitement at Convention 2018!

32 CCGI Appoints New Knowledge Brokers

34 CCRF Refines National Research Priorities

37 Champion Profile: The Personal®

38 Population Density Map: Recognizing the Importance of Chiropractic Clinic Locations Across Canada

Be Proactive: Managing Risk in Your Practice5

The Pain Trials: Emerging Research in DLSS22

Back to Basics: What's New in International Back And Neck Pain Research18

Chiropractic and Concussion:New Consensuses in Concussion in Sport

14


Issue 14, 2017

[email protected]

BACK Matters™ is a publication of the Canadian Chiropractic Association (CCA) and is published two times per year.

Copyright © 2017 Canadian Chiropractic Association. All rights reserved. The opinions expressed in this publication are those of the authors and do not necessarily reflect the opinions and policies of the CCA. Advertisements shall not be considered an endorsement, warranty or guarantee of the product(s) or service(s) advertised, nor an endorsement by the CCA of the manufacturer, distributor, supplier or advertiser of such product or service.

No part of this publication may be reprinted without the editor’s written permission.

Published by the CCA

Editor: Ronda Parkes

[email protected]

Tel: 416-585-7902 Toll Free: 1-877-222-9303 Fax: 416-585-2970

Publications Mail Agreement No. 40036842

Return undeliverable Canadian addresses to: 186 Spadina Ave, Suite 6, Toronto, Ontario M5T 3B2

C011603

Paper fromresponsible sources

MIX

CONTRIBUTORS

DR. GREG DUNN, DCDr. Greg Dunn graduated from CMCC in 1976. He had an active practice in Manitoba until June 1999. Dr. Dunn served on the Board of the Canadian Chiropractic Protective Association (CCPA) from 1990 until his appointment of COO in September 1999. While serving on the CCPA Board, Dr. Dunn became Chair of the Risk Management Committee. Dr. Dunn is also a national and international lecturer on the topic of risk and risk management. Currently, Dr. Dunn serves as the CEO of the CCPA. Dr. Dunn is a past president of the Manitoba Chiropractors’ Association and a past president of the CCA. Dr. Dunn has been very active in community volunteer work. He co-chaired the 1992 Manitoba Summer Games, was a founding member and first Chairman of the Beautiful Plains Community Foundation Inc., and was the leading force in getting Canada Post to issue a centennial stamp commemorating one hundred years of chiropractic in Canada.

DR. ADRIAN CHOW, DCDr. Adrian Chow obtained his Honours Bachelor of Science from the University of Toronto in 2012 and his doctor of chiropractic degree from Canadian Memorial Chiropractic College (CMCC) in 2017. During his final year at CMCC, Dr. Chow served as a chiropractic intern for the Canadian Chiropractic Association (CCA). Although he is currently focused on his private practice in Richmond Hill, Ontario, he continues to hold an active role at the CCA. Dr. Chow has a strong interest in interdisciplinary collaboration and is actively involved in the advancement of the chiropractic profession.

DR. JULIE YAWORSKI, DCDr. Julie Yaworski graduated from the University of Saskatchewan in 2013 before graduating from CMCC in 2017. Dr. Yaworski recently served as a chiropractic intern for the CCA of her final year at CMCC. Along with her continued involvement with the CCA, Dr. Yaworski is currently in private practice in Swift Current, Saskatchewan. Dr. Yaworski has an interest in female healthcare and leadership as well as community development. She hopes to aid in advancing chiropractic in small communities and to contribute to advancing the profession at a national level.

DR. SCOTT D. HOWITT, MSC, RKIN, DC, FRCCSS(C), FCCPORDr. Scott Howitt holds an Honours Bachelor of Arts in Physical Education from the University of Western Ontario and a master’s in Human Health and Nutritional Sciences from the University of Guelph. He graduated from CMCC and completed a two-year postgraduate residency in sports sciences and a three-year postgraduate program in rehabilitative sciences. Dr. Howitt was a member of the core medical team for Canada at the 2015 Pan Am games and works with various amateur and professional athletes in his private practice. Dr. Howitt is the chiropractic representative for the Canadian Concussion Collaborative and sits on the National Advisory Council for Exercise is Medicine Canada. He is also an associate professor at CMCC, sessional instructor at University of Guelph at Humber, and varsity chiropractor at York University.

DR. REBECCA HOLMAN, DCDr. Rebecca Holman was born and raised in Hamilton, Ontario. She graduated with a Bachelor of Arts in Health Studies from Queen’s University in 2011 and a doctor of Chiropractic degree from CMCC in 2015. Dr. Holman currently provides care at a clinic in Estevan, Saskatchewan. In her practice, Dr. Holman focuses on manual therapy and rehabilitation exercises. She is also a certified acupuncture provider, a strength and conditioning coach, and has taken courses on delivering conservative care to pregnant women for musculoskeletal pain. Her love for running and CrossFit and her participation in many team sports has enabled her to understand the athlete’s perspective of injury and the game. Dr. Holman is also an active Rotarian and volunteer in her community.

DR. CARLO AMMENDOLIA, DC, PHDDr. Carlo Ammendolia is the Director of the Chiropractic Spine Clinic and the Spinal Stenosis Program at the Rebecca MacDonald Centre for Arthritis and Autoimmune Diseases at Mount Sinai Hospital. He received his MSc degree in Clinical Epidemiology and Health Care Research and his PhD in Clinical Evaluative Sciences from the University of Toronto. Dr. Ammendolia is an Assistant Professor in the Institute of Health Policy, Management and Evaluation, the Institute of Medical Sciences and Department of Surgery at the University of Toronto. In 2012, Dr. Ammendolia was awarded the Canadian Chiropractic Research Foundation (CCRF) Professorship in Spine Award from the Department of Surgery in the Faculty of Medicine. He has been in clinical practice for over 35 years and now combines clinical practice and research in the area of non-operative treatment of mechanical, degenerative and inflammatory spinal disorders with a special interest in lumbar spinal stenosis.

DR. SIMON FRENCH, BAPPSC (CHIROPRACTIC), MPH, PHDDr. Simon French is an Associate Professor and holds the CCRF Professorship in the School of Rehabilitation Therapy, Queen’s University. He is also a full Professor at the Department of Chiropractic, Macquarie University, Australia. He completed his PhD at the Australasian Cochrane Centre, Monash University, in 2009, and undertook his post-doctoral position at the School of Health Sciences, University of Melbourne, where he was supported by a Primary Care Research Fellowship from the Australian National Health and Medical Research Council. Dr. French conducts research in the area of knowledge translation in primary healthcare settings with a focus on the management of low back pain and osteoarthritis. He also undertakes randomized controlled trials and systematic reviews of interventions relevant to primary care settings. He is Deputy Editor-in-Chief of the open access journal Chiropractic & Manual Therapies.


Chiropractors protecting chiropractors. This phrase has become synonymous with the Canadian Chiropractic Protective Association (CCPA) over the years for good reason. We are always working to ensure that you are protected in the event of a professional negligence claim. Along with a network of lawyers and experts across the country, CCPA’s team of chiropractors has gotten very good at managing claims and seeing our members through these difficult experiences.

But you don’t ever want to have to call us. We get it. We see every day how traumatic an incident in practice or a claim can be. That is why we produce the annual Risk Management Project. For over 25 years, these projects have been a tool to help you manage risk in your own practice.

The 2017 project builds on The Road Map to Care by delving deeply into The Art of

Evidence-Informed Treatment Plan Design. This 30-minute project offers a refresher on building customized, achievable, and measurable treatment plans that help you get results with your patients and mitigate risk in your practice. CCPA thanks the Canadian Chiropractic Guideline Initiative for their help in creating this project.

We have made a few changes this year. The 2017 project is broken into a series of short video chapters that you can work through at your own pace. You can even go away and return to the project right where you left off. These changes are based on valuable feedback from our members. That feedback is so valuable that we have replaced the usual quiz with a short survey about your experience with the project.

Our website also hosts an archive of several past risk management projects that you can download and review at your

own pace. These cover some great topics, such as The Road Map to Care, The Five-Minute Neuro Exam, and What Gets US into Trouble. The latter includes specific advice on how to manage some of the toughest situations you will face in practice.

These projects are part of the collection of services we offer to help you manage risk in your practice. We are also here to offer one-on-one support if you are facing a challenging situation with a patient and do not quite know how to proceed.

So, at the first sign of trouble in your practice, please contact CCPA at 1-800-668-2076 or email us at [email protected].

BY DR. GREG DUNN, DC CEO, CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION

Proactively Managing Risk in Your Practice


THE ROAD TAKEN, AND WHERE IT LEADS US

DR. DAVID PEEACE, DC Chair, CCA Board of Directors

MESSAGE FROM THE CHAIR

“… Two roads diverged in a wood, and I—I took the one less travelled by,

And that has made all the difference”

– Robert Frost, “The Road Not Taken”

I am sure we have all read or have heard this incredibly famous quote from Robert Frost’s poem, “The Road not Taken.”

I have heard it quoted at commencement

ceremonies and even used by a few

motivational speakers at seminars and

conferences. This poem is often used to

applaud those that have chosen to follow

a path that was not the routine or one that

went against the grain. It is thought to be

a triumphant celebration of self-assertion

or a willful choice to be non-conformist,

with accolades that follow.

This false assumption is one of the reasons for

this poem’s familiarity. Too often, this poem

gets quoted out of context and not fully read;

in fact, both roads are virtually the same. There

is no difference in either road and most likely

they will end in the same destination.


Perhaps this is a good metaphor for our own profession, and how we have taken (or are perceived to have taken) an alternative road to patient care—how some in our profession feel they have taken the road less travelled and have embraced that path as our core individuality, different from (and perhaps in opposition to) the mainstream road of healthcare.

When we define ourselves as being alternative or different from the status quo we are without an independent definition amongst healthcare practitioners. Instead, we become defined by what we are not. This is inherently a weak position. We should rather be defined by what we are: we are healthcare providers, and we treat patients.

Looking at definitions unto themselves should not be at the forefront of changing perceptions of the profession. Let me be clear that this message is not about self-definition, it is about public perceptions and focusing on our shared goal: helping the patient. For me, there is nothing more grounding and unifying than when we focus on the patient, which is what has driven us to our profession in the first place.

Time and time again, when national and international surveys and questionnaires are done, we are reminded that patients and the public know who we are and what we do. Our patients want us to be team players; they want us to be communicating with their family physician and their healthcare team. Our patients don’t ask us to define ourselves, they ask us to help them feel better.

We need to invest in the patient perspective and see the experience of receiving care through the patients’ eyes. One way to alter negative perceptions of practice is to provide consistently positive experiences. Having confidence in the value of what we do and in the positive impact our profession brings to the health of Canadians is what builds trust and credibility and allows us to advance the profession within the healthcare system.

When we define ourselves as being alternative or different from the status quo we are without an independent definition amongst healthcare practitioners. Instead, we become defined by what we are not. This is inherently a weak position. We should rather be defined by what we are: we are healthcare providers, and we treat patients.

To the broader healthcare system, the quality of our manual skills and education is relevant only and entirely as they relate to patient outcomes. Governments and health-system

leaders are beginning to recognize the challenges of musculoskeletal issues and the burden they place on the healthcare system, but this burden is still not a priority. Inefficiencies in the healthcare system with respect to pain management have contributed to big issues like the opioid crisis. Non-pharmacological pain management is needed now more than ever.

For me, there is nothing more grounding and unifying than when we focus on the patient, which is what has driven us to our profession in the first place.

Our shared intentions are to help patients relieve pain and restore function. However, good intentions can be thwarted by negative perceptions. What we do in the public domain—and we must remember that we are always in the public domain, in our offices, on social media, or even out in public in non-clinical settings—is under scrutiny. The credibility of the profession suffers when there is false advertising, debates surrounding the validity of vaccination, or claims that chiropractic care can cure illnesses that are outside the scope of the musculoskeletal system. Good intentions can lead to unintended perceptions and that is damaging to the patients that need our help and to the wider healthcare system that is in need of better alternatives to pain management.

We have not reached a place of granite credibility. As such, we must continue to demonstrate our professionalism, continue focusing on our patients, and support all that we do with evidence.

We are evidence-informed practitioners. We owe it not only to ourselves and the profession, but to the millions of people who put their trust in our hands every day to put our best foot forward. We need to be wary of the perception that comes from engaging with the public in areas that are not yet supported by adequate research. If you put patients first, you will find yourself among some of the greatest supporters and advocates. They lie at the end of both those roads.

“… Then I took the other, as just as fair, And having perhaps the better claim,

Because it was grassy and wanted wear; Though as for that the passing there

Had worn them really about the same...”

– Robert Frost, “The Road Not Taken”

The CCA wants the profession to feel empowered. Our vision is that chiropractors will be an integral part of every Canadian’s healthcare team by 2023. We all have an important role to play as we travel this road together.


UNPACKING BARRIERS

MESSAGE FROM THE CEO

ALISON DANTAS CEO

Earlier this year, the Canadian Chiropractic Association (CCA) was invited to make a presentation at the Canadian Life and Health Insurance Association (CLHIA) conference to insurers, claims adjudicators, fraud adjudicators, long-term disability representatives, and researchers hired by insurance companies. Part of the CCA’s goal was to advocate for why chiropractic matters, but, more importantly, the goal was to advocate for greater coverage for chiropractic care.

This year, the CCA was the only paramedical service provider represented at the CLHIA conference. The CCA’s ongoing advocacy work has been pushing for awareness and acceptance of non-pharmacological pain management. With the rising awareness of the opioid crisis came the climate necessary to discuss pain and chiropractic’s role, and it helped bring the CCA in front of one of its largest stakeholders. The profession is positioned to be seen and heard now more than ever.

There were many things the CCA took away from the CLHIA conference. While we are acutely aware of the benefits of chiropractic care, the CCA was reminded that there are still barriers to discussing the coverage of chiropractic within the extended healthcare industry. At that conference, there was still diversity to the understanding and awareness of the chiropractic profession. Dr. Robert David, former CCA chair, and I accepted that there was a need to take time to relay the groundwork with extended healthcare providers in order to take the conversation further. We had to debunk myths and perceptions that do not represent the profession as a whole. Before we could discuss greater coverage, we had to take steps to educate, inform, and advocate.

The profession has so much of which to be proud. You know the value of chiropractic and what it can do to help patients. Chiropractors are held in high regard by allied healthcare practitioners and by those they treat. With Canada-wide regulation, extensive training, and expertise in musculoskeletal (MSK) health, chiropractors are being recognized in greater numbers. These strongholds have been necessary for our work in gaining greater integration into the Canadian healthcare system. Every marker of advancement of the profession has been extremely important in gaining new ground towards the vision of making chiropractors an integral part of every Canadian’s healthcare team.

However, in reality, the behaviours that lie at the edges of regulated practice and push the boundaries can impact the entirety of chiropractic in areas where it needs to make strides—in insurance coverage, government affairs, media relations, and wider public recognition of the value of and need for chiropractic availability and affordability.

From the standpoint of insurers, how chiropractors engage with their patients is not visible. They do not see the treatment and the good work that chiropractors do. They often only see the end result of an invoice. Insurers have a harsh bottom line and are concerned with financial conservation. If there are weaknesses in any service they cover, they will take an opportunity to highlight it to support their bottom line (which may result in less coverage or no coverage at all). In this conversation, we must acknowledge that some of the profession’s weaknesses lie in business practices and in claims of having cures for chronic diseases that lie outside of the realm of MSK health. False advertising and unchecked messages on social media platforms also continue to impact perceptions of the profession.

Advocating for better awareness in extended healthcare—what’s holding us back?


Specific problem scenarios arose at the CLHIA conference. A large concern from the extended healthcare community stems from billing patterns, including contracts. The concerns of the insurers matched those presented in the CCA’s public opinion poll in 2014: contracts, as perceived by the public, are seen as a financial strategy that puts the business before a patient’s treatment. Conference attendees asked how they could justify reimbursing patients for a maximum number of sessions if they’ve paid for them all up front, particularly since insurers know that compliance is an issue and patients leave treatment when they feel better. As such, why would they opt to pay an invoice for $2,000 if a patient has only received $500 of care? The participants pushed the point that if the leading evidence says that patients will see improvement for a specific condition in eight to 12 visits, why don’t the invoices they receive from chiropractors align with that statistic?

With respect to pediatrics, insurers have a stake as well: with increasing numbers of children and teenagers using chiropractic care, they need to ensure practices are safe, effective, and evidence-based if they are to continue funding it. Dr. David provided many examples of the care chiropractors provide to their pediatric patients. He demonstrated that chiropractors are trained to treat this cohort and that research continues to emerge in this area of clinical treatment. The caution I pose to the profession is that the skepticism that arises in public forums about treatment of children is often fed by videos that appear online of babies having their backs and necks audibly adjusted. There is no doubt that if this continues, chiropractic coverage could be affected.

Pediatric discussions spilled into the realm of vaccination. From the perspective of extended healthcare, with media reports showing chiropractors informing the decisions of young parents to not vaccinate their children, it feeds the public perception that chiropractors are campaigning against public health protocols. The CCA’s position statements on vaccination and public health have helped to clarify where the profession stands—that vaccination lies outside of the scope of chiropractic care. Having a consistent message builds trust and positive relationships with extended healthcare providers and reassures them that any personal views that differ lie outside of that position. When people speak and operate outside of the regulated scope and profession-wide positioning, there is a risk of damaging the bridges built between chiropractic care and healthcare coverage.

Ultimately, evidence plays a large role in the parameters set forth by insurance companies. Insurers are motivated by evidence-informed practices—they are consistent, efficient, and build credibility. Changes in this model are not taken lightly. Insurers asked the CCA what it does about behaviour that is inconsistent with outlined standard practices. For now, truthfully, the responsibility sits with those individuals and with the regulatory bodies that govern chiropractors in their jurisdiction. Primarily, it is up to every chiropractor to practice within the prescribed scope and stay out of practices or discussions that fall outside of it. Insurers are paying millions of dollars every year to support chiropractic care, and in return, they want to ensure consistency, transparency, and credibility.

One of the biggest challenges the CCA currently faces as a national association comes from reframing chiropractic care and showing it as (1) an overall benefit to the healthcare system and (2) as a conservative care option that relieves the burden of disease that comes with MSK health concerns, including neck and back pain.

In light of the pain epidemic and the opioid crisis, the CCA has been able to paint a bigger picture of the role chiropractic can play in changing Canada’s approach to pain management. For those at the CLHIA conference, the CCA highlighted that chiropractors play an important role in relieving the burden of long-term pharmacological interventions for pain—which is in itself a financial burden for insurers.

In discussing the pain epidemic, the CCA discovered that for extended healthcare providers it was a new perspective to see the opioid crisis framed as a back pain crisis. They wanted to know more. The CCA also learned that within extended healthcare, there has not been a clear perception of the burden of disease for back and neck pain.

The good news is that these discussions are happening now. The opioid crisis that this country currently faces has opened the conversation to expose the connection between pain, medication, and long-term addiction in greater detail. The pain epidemic also re-opened the discussion of how pain impacts productivity in the workforce, its connection to disability, and how that, too, has a great burden on workers, employers, and insurers.

As chiropractic advocates, the CCA is in a position where it must work through these barriers that are preventing access to better healthcare coverage. It is challenging to face harsh questions, be open rather than defensive, and educate stakeholders about MSK health, evidence-informed practice, and the expertise of the profession. I think, for those present at the CLHIA conference, new dialogue channels were opened. The CCA took the questions of attendees seriously. The conference presented a great opportunity to have an exchange with valued stakeholders, even in the most heated discussions and challenging conversations. With more of these conversations, the CCA hopes to shift attitudes.

The CCA is ready to take on the key issues—beyond those barriers—and it is working hard for its members to do so. The profession has incredible potential to serve even more Canadians given the burden of MSK diseases and the opioid crisis. Evidence-informed practices, clinical guidelines, interprofessional protocols, and research are the cornerstones of the profession that will ensure the momentum and uptake of chiropractic continues. The CCA’s work with insurers is a key priority. We know it matters a great deal to our members and to patients. Together, by focusing on best practices and avoiding feeding negative perceptions, we can achieve the vision of the CCA—that every Canadian will have a chiropractor as an integral part of their healthcare team by 2023!


SPOTLIGHT ON

Building presence in small-city Saskatchewan

TAKING THE LEAD

BUSINESS PROFILE

Dr. Rebecca Holman, DC

Dr. Nalli answers a patient question during a live show.

W hen Dr. Rebecca Holman graduated from the Canadian Memorial Chiropractic College (CMCC) in 2015, she never dreamed she’d be moving to small city Saskatchewan to join a thriving practice and plant new roots.

Born and raised in Ontario, having spent a number of years in Toronto, she was accustomed to city life. Imagine the culture shock that came with her move to Estevan, the eighth-largest city in Saskatchewan, with a population of just over 11,000.1 Despite the definition of “small city,” to Dr. Holman, Estevan really felt like a small town.

Her first exposure to chiropractic care came as an athlete in university. After sustaining an injury, she sought treatment from a sports clinic that included physiotherapists and chiropractors. Although she was largely treated by her physiotherapist, it was in this environment that she was first exposed to chiropractic treatment. She was blown away by how much training, knowledge, and expertise the chiropractor was able to provide in treating her, beyond what she had experienced under the care of the other providers at the clinic.

Dr. Holman’s undergraduate degree was in public health. She knew she wanted a career with a healthcare focus, but it was that exposure to the profession that led her down the path to becoming the chiropractor that she is today.

Dr. Holman’s connection to Saskatchewan began right after she graduated from CMCC, where her partner (now husband and colleague) was a year ahead of her. Following a presentation he had attended at school by Dr. David Peeace, he found an opportunity to practice out West. He moved to Estevan, and it was through him that Dr. Holman learned about the externship opportunity at the same clinic, which became her first step towards the life she has built for herself today.

In Estevan, their clinic is the only one with chiropractic services within an hour drive of the city. It has been around for decades and Dr. Holman’s predecessors have worked hard to build the trust of

the community. Dr. Holman credits the longevity of the clinic as part of its success and does not underestimate the value of long-built, hard-earned reputation and trust that has allowed the practice to thrive: “It’s been here for over 50 years with various chiropractors. My predecessors—Dr. Peeace, Dr. Robert Kitchen, and Dr. Hugh Armstrong—worked hard to build trust within the community.”

Having a shared set of values with the founders of the clinic, which includes patient-focused and evidence-based practice principles, has also allowed the team to maintain consistency and have a stronghold within the community: “We’re all very like-minded. We’re all on the same page and we work well together. There’s no confusion as to what chiropractic is, what services we offer, and what we can do to help patients.” She acknowledges that in giving the same sort of messaging to patients, they are not getting different sorts of philosophies or ideas from different practitioners within the clinic, and says they worked hard to build their reputation.

One thing that comes with working in a small population is that they don’t specialize, “because we can’t. It’s too small of a population and I prefer it that way. It keeps you on your feet.” Dr. Holman and the other chiropractors in the clinic have a wide variety of patients with diverse needs, and they are the only chiropractors in Estevan to help them. She admits there is a high turnover of healthcare professionals in the area and that it is under-serviced generally in terms of medical doctors.

Given the size of the city and the resources available, Dr. Holman and her chiropractic colleagues are often primary care providers for their patients: “We run a strictly musculoskeletal practice, so people tend to only come to us for those types of things, but they generally come to us first, for sure.”

When asked about what sort of outreach work she does, Dr. Holman says typical outreach initiatives—those which involve going out and making organized presentations to schools and businesses—would not necessarily be worthwhile in a small city, “It’s more effective to try and be a leader and to be a trustworthy person in the community. Being present and

“We’re all very like-minded. We’re all on the same page and we work well together. There’s no confusion as to what chiropractic is, what services we offer, and what we can do to help patients.”


being a person people can identify with is really helpful. That is why we work to make ourselves known and why we work at being leaders.” In terms of her own involvement, Dr. Holman is part of her local rotary club and gets involved with a fair bit of charity work, including volunteering with her colleagues last Fall with the Salvation Army on a winter socks drive for those in need. She’s also involved in sporting activities and coaching. As a part of the CrossFit community, she has also had the opportunity to run a couple of seminars and workshops for her peers, which she has organized by request.

What is important to remember, wherever you live and practice, is to network with other healthcare practitioners. In Estevan, Dr. Holman felt this was especially important. She has met with local medical doctors, optometrists, dentists, physiotherapists, and other healthcare professionals individually for lunches and coffees to talk about the profession, partly because “there is a little bit of confusion about what chiropractic can offer.” With the high turnover of professionals, it is important to make sure you introduce yourself to everyone who is new in order to continue the relationships of trust between the professions. She says while she has made good inroads with some of the new medical doctors in Estevan, she has followed the leads of both Dr. Peeace and Dr. Kitchen who came before her.

Dr. Holman and the chiropractors in her clinic have also hosted professional meets that include local medical doctors, dentists, optometrists, and other healthcare professionals. She says that because they co-manage patients and work with many of these healthcare practitioners interprofessionally, it is an important type of event to attend: “Those professional meets have been good, just talking about our scope of practice and what we can handle and what they need to handle.” This, she says, is the key to integrating into the wider healthcare community and how you generate understanding, openness, referrals, and better treatment for the patient.

WHAT ADVICE DOES SHE HAVE FOR NEW GRADUATES?“I would very much recommend new graduates, if you want to

be successful quicker, to go to a small town or city where your services are very much needed. Network with other healthcare practitioners in the area right away and let them know that you’re there. Then, be a part of the community—and not those formal outreaches—be a part of a club of some sort, or be a part of a sporting activity. Get involved in the community.”

She also advises for new graduates to keep in mind that opportunities can show up in the unlikeliest places. So keep your eyes open and be open to working outside of your comfort zone. “I have learned a lot about myself in this process, in moving to a small city, away from home, and getting out of my comfort zone. I have never lived in a small city before. It has treated us very well.”

One thing that connects us across city limits is having an online social presence. When it comes to building a social presence online, however, she admits that while she has a professional Facebook page for herself, her clinic is busy and time is limited, “We don’t have a live website, although it’s on its way. We are almost there with that.” However, they do have someone on staff in charge of social media who posts a couple times a week, and they use and share CCA materials (blogs and other posts) in order to make their lives a bit easier: “before we hired someone, we didn’t do very much online at all. When we realized we didn’t have the time to really make a good Facebook page, we hired someone to help us out with that—and they’ve done a great job. But it’s all CCA stuff, we make sure it’s backed by evidence.”

Estevan, Saskatchewan may not have been on Dr. Holman’s radar a few years ago, but it is a place she has very quickly come to love. “It’s different,” she says, but it’s now home, and she wouldn’t change it for the world.

Reference

1. Statistics Canada, 2016 Census.

(From left to right) Dr. David Peeace, Dr. Rebecca Holman, and Dr. Trevor Erdie


COMMUNICATIONS

RONDA PARKES CHIEF BRAND OFFICER

I t is common practice these days for businesses and professionals to have a robust online presence through social media, blogs, and more. These digital communication tools allow chiropractors to showcase their expertise to a wider audience and engage more patients in need of a spine, muscle, and nervous system expert. Online content also goes a long way towards informing public opinion about the profession as a whole.

Using pictures, videos, and stories that focus on general awareness of chiropractic practices, your skills and expertise, and the potential health benefits of chiropractic care, can position your business and the profession as safe and trustworthy for spine, muscle, and nervous system health.

You are highly-skilled professionals that represent a crucial part of the healthcare system. Unfortunately, not everyone is aware of the great work that you do. That’s why it is so important to reinforce the message that chiropractors are spine, muscle, and nervous system experts.

For some people, your online communications will be their first introduction to chiropractic care, so it is important to make a good first impression. Online engagement can be useful for your practice, but, it can also put you and the profession at risk if your communications contradict popular opinion or established medical practices.

There’s no greater example than a recent social media post where a family chiropractor entered a hospital to perform an adjustment on an infant patient that had been receiving care. The chiropractor in question captured images of the treatment and posted it on social media.

As well-intentioned as this may have been, the procedure was performed on the premises without proper consent from hospital management.

This circumvention of the rules by even one person can cause some legitimate public concern. After being notified, the hospital in question responded through social media.

The tweet from CHEO Hospital Ottawa, which paints the occurrence in a very negative light, has the potential to change public opinion about all chiropractors. Prospective chiropractic patients may apply the actions of one individual to the entire profession and choose another healthcare option altogether.

The old saying that one bad apple can spoil the bunch definitely applies to public opinion. Each online message about chiropractic impacts you directly, and the entire industry indirectly.

Another example that diminishes the profession is promoting health benefits that have not yet been proven in a clinical environment. There are many treatments and techniques in practice today in the healthcare landscape with varying degrees of efficacy, but it is unfair and unprofessional to promote a clear health benefit until there is the evidence to back it up. Cancer, for example, has no cure, but there is a gold-standard for treatment that constantly evolves as new evidence is brought to light.

Musculoskeletal treatment is no different.

In today’s world of widespread internet access, information can quickly and easily be fact-checked, cross-referenced, disproven, and even ridiculed in public so it is important to use the most substantiated and up-to-

date information on hand. The risks of making claims that are outside of the scope of practice have the potential to impact the perception of chiropractic in a less-than-positive light while causing harm to the practices of friends and colleagues in the profession.

Every DC carries the brand of “chiropractor.” If one chiropractor shares an opinion or unsubstantiated fact it can impact the entire profession.

ADVERTISING AND FALSE CLAIMS

How careful do we need to be and what are the risks for the profession?


Evidence-informed practice principles are widely accepted within our healthcare system, but some questions are worth asking. How is that evidence being interpreted and used? How well-informed are patients in their treatment? And how is all this being communicated to the general public?

While there are many treatments and techniques that fall between evidence-informed and unproven, it is important to advertise care options and benefits openly and honestly. This not only establishes you as a trustworthy healthcare professional, it helps create consistency throughout the profession so the patient experience is uniformly positive while positioning chiropractors as spine, muscle, and nervous system experts with an evidence-informed approach.

It is important to always consider, (1) what do you think about when you place an advertisement on social media, and (2) how is that perceived? It is all too easy for the public to misunderstand messaging, particularly if they bring preconceived notions or misinformation to the table before they even see or engage with advertisements.

When it comes to mitigating the risks of false advertisement claims, the CCA’s position statements help set a solid footing in our stance on important public health concerns, including the importance of vaccination. These exist to help guide the communications materials of the profession and inform the public and the media of our stance on a variety of important issues that affect Canadian chiropractors and their patients (you can find these on chiropractic.ca under the “About CCA” drop-down menu).

Research is important in everything we do. It informs chiropractic practice. It ensures chiropractors are working with the most up-to-date evidence when treating patients every day. We know that you value the wealth of research that has enriched your chiropractic education and has continued to do so over years of practice. The CCA’s work with the Canadian Chiropractic Research Foundation—to address the research priorities of the professional associations across the country and continue to build the credibility of the profession—was another measure to help the profession stand its ground.

However, we need your help in taking a critical eye to all materials you publish and promote in the public sphere. As leaders in spine, muscle and nervous system health, patients look to you for guidance. Your patients respect and trust you, and their perception of the profession is in your hands.

Now, more than ever, we are visible. This is a great thing. We need to use this power and influence wisely. I know that, through vigilance, our profession can take flight, and our vision looks brighter than ever.

One last thing. Are you looking for more quality content to share online? Connect with us on social media where we regularly share news, information, and helpful tips to keep chiropractic care strong and well-represented in Canada.

Here are our recommendations for best practices when creating public-facing content, including social media posts and advertisements:

Review the CCA’s position statements at chiropractic.ca

Review your province’s regulatory rules. Stay in scope

Adjust your social media settings to determine who sees personal posts and business posts (privacy settings)

Follow the CCA and your provincial association on social media. Browse the CCA’s blog. You can find content to share, or use it for inspiration

Log-in to the members side of the CCA website and browse the resources section for content (which includes infographics, PDFs, and exercises videos)

Share pre-approved public content from your associations

If you’re not sure, ask! Don’t be afraid to contact the CCA if you have any questions about public-facing content. Email [email protected] with your questions.

Online engagement can be useful for your practice—it can also put you and the profession at risk if your communications contradict popular opinion or established medical practices.

Social Media Best Practices Checklist


F or those not familiar, the mission of the Canadian Concussion Collaborative (CCC) is to create synergy between 12 leading health and sports organizations concerned with concussions in order to improve education about concussions and the implementation of best practices for the prevention and management of concussions.

The CCC has an important role to play in the development and adaptation of innovative and multidisciplinary concussion management approaches that will improve the quality of care for concussed Canadians.

It is significant to highlight that chiropractors play an important role as primary healthcare providers in identifying patients who have been concussed. The chiropractic involvement in health promotion and its contribution to concussion prevention strategies has not gone unnoticed. The profession’s ability to add to an evidenced-informed approach to concussion management has been recognized as an invaluable contribution to concussion treatment and prevention.

New findings in concussion research continue to emerge, shaping chiropractic treatment strategies and best evidence practices. The 5th International Consensus Conference on Concussion in Sport, held in Berlin in October 2016, produced several important publications including the latest consensus statement which was published in the British Journal of Sports Medicine in April 2017.1

The CCC, which is made up of 16 health organizations including the CCA and the RCCSS(c), has published numerous resources, including a recent up-to-date summary of concussion management concepts from the recent consensus statement.2

For those already familiar with the 4th iteration of the consensus statement,3 here is a summary of five of the key messages that came out of this year’s international consensus statement, which should be read in conjunction with the full version of the Berlin consensus statement:

CHIROPRACTIC AND CONCUSSIONS

In the wake of the 5th International Consensus Conference on Concussion in Sport, new consensuses have emerged

BY DR. SCOTT HOWITT, DC, CCA/RCCSS(C) REPRESENTATIVE, ON BEHALF OF THE CANADIAN CONCUSSION COLLABORATIVE

CLINICAL FEATURE


1. Prolonged rest until all symptoms resolve is no longer recommended After an initial short rest period lasting 24–48 hours, the early introduction of light cognitive and physical activity can be initiated, as long as the activity does not exacerbate symptoms (sub-threshold activities).

2. A gradual return-to-school (cognitive activity) strategy has been detailed A four-step graduated return-to-school strategy has been proposed. It is recommended that children and adolescents return to full-time school activities before they return to sports; however, initiation of physical activity can occur prior to a complete return to school.

3. Progression through the recovery process should be guided by the symptom exacerbation threshold Gradual return to sub-threshold cognitive activities and low risk individual physical activity can progress as long as they don’t increase symptoms. However, complete symptom resolution should be achieved before participating in activities placing the individual at risk of concussion (e.g., non-contact training drills). Also, the statement emphasises the importance of respecting a minimum of 24 hours between each step of the return to sport protocol and obtaining medical clearance before resuming sport-specific activities that may place the individual at risk of concussion.

4. The use of baseline testing is not necessary The Sport Concussion Assessment Tool 5 (SCAT5)4 is considered useful to help healthcare professionals assess for the possible presence of a concussion immediately after an injury, but should not be used as a stand-alone method to diagnose a concussion. The utility of the SCAT5 as a screening tool appears to decrease significantly 3–5 days after injury. SCAT5 baseline testing is not necessary for interpreting post-injury scores. In addition, based on current evidence, the widespread routine use of baseline computerized neuropsychological testing is not recommended in children and adolescents. When these tests are used in the post-injury setting they should optimally be performed and interpreted by an accredited neuropsychologist.

5. Persistent post-concussive symptoms should be reassessed to identify associated conditions and define an individualised treatment plan The strongest and most consistent predictor of slower recovery from a concussion is symptom severity in the initial few days after injury. The symptom checklist demonstrates clinical utility in tracking recovery. Based on the evolution of most concussions, the notion of “persistent concussion symptoms” has been re-defined as greater than two weeks for adults and four weeks for children. When symptoms persist beyond this expected time frame, a medical re-evaluation should be obtained to develop an individualised treatment plan. Attention should be given to recognizing and managing of the following conditions: autonomic system dysfunction, physical deconditioning, cervical spine problems, vestibular dysfunction, and mood problems. Care of patients with persistent post-concussive symptoms should optimally be managed in a multidisciplinary setting by a team of healthcare providers including a physician with experience in sport-related concussions.

CONSENSUS STATEMENT ON CONCUSSION IN SPORT


In support of this mission, the CCC previously published two key recommendations in the British Journal of Sports Medicine.5 The recommendations outlined the key elements of an effective concussion management protocol and the important role a multi-disciplinary health team can play in helping manage concussions, particularly in high-risk sports:

1. Organizations responsible for operating, regulating, or planning sport and sporting events with a risk of concussion should be required to have in place, and annually review, a concussion management protocol based on current best practices, customized for the specific sport and available resources. Best practices include (but are not limited to) planning for education, knowing the steps to take should a concussion occur, and ensuring that all resources are current and accessible.

2. In situations where timely and sufficient availability of medical resources and/or trained and licenced health professionals qualified for concussion management are not available, health professionals from various disciplines should work together to improve concussion management outcomes by facilitating access to medical resources and relevant expertise where appropriate.

As previously published, these two recommendations were unanimously endorsed by both the CCA and RCCSS(c).

The chiropractic profession is seen as a valuable member of the CCC, making significant contributions to the educational pieces and tools the CCC will continue to create. Chiropractic contributions to the CCC ensure that Canadian chiropractors will be informed of the CCC’s education efforts as they continue to better prepare primary care and emergency resources for best practices in multidisciplinary concussion management.

References

1. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;0:1-10. doi: 10.1136/bjsports-2017-097699.

2. Canadian Concussion Collaborative Concussion Resources. Published by the Canadian Academy of Sport and Exercise Medicine. Available at: http://casem-acmse.org/concussion-related-position-statements-tools/. Accessed August 18, 2017.

3. McCrory P, Meeuwisse W, Aubrey M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250-8. doi: 10.1136/bjsports-2013-092313.

4. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5). Br J Sports Med. 2017. pii: bjsports-2017-097506. doi: 10.1136/bjsports-2017-097506. [Epub ahead of print]

5. Fremont P, Bradley L, Tator CH, Skinner J, Fischer LK. Recommendations for policy development regarding sport-related concussion prevention and management in Canada. Br J Sports Med. 2014;0:1-2. doi: 10.1136/bjsports-2014-093961.

The profession’s ability to add to an evidenced-informed approach to concussion management has been recognized as an invaluable contribution to concussion treatment and prevention.

CLINICAL FEATURE


Morneau Shepell is Canada’s only human resources consulting and technology company that takes an integrative approach to employee assistance, health, benefits, and retirement needs.

Our clients are progressive leaders seeking to enhance the health, productivity, and financial security of their employees. With more than 4,000 employees in offices across North America, we apply our combined consulting, outsourcing, and technology expertise to help them succeed.

Established in 1966, Morneau Shepell currently serves approximately 20,000 clients ranging from small businesses to some of the largest organizations in North America and around the world.

In the Canadian market we are the industry leader in a number of areas including Employee and Family Assistance Programs, integrated absence management, and technology and outsourcing solutions for retirement and benefit plans. We are proud to be the official Mental Health Partner of the Canadian Olympic Team.

For over a decade, Morneau Shepell has partnered with the CCA to offer a Group Benefit Program, which means we have CCA members covered.

Comprehensive insurance coverage for CCA members

As a Champion Corporate Partner, we look forward to continuing to work with the CCA to make it easier and more affordable for its members to protect their business, income, and family.

Visit cca.hroffice.com for details. ©2017 Morneau Shepell Ltd. | MS-CCA 08-2017

1.866.432.8427 [email protected]

Contact us today

CCA-specific services

CCA members can take advantage of group buying power to purchase affordable, comprehensive insurance coverage.

We have helped the CCA create a benefits program tailored to their members’ needs by providing the flexibility and options they require, at competitive rates usually offered only to large companies. From an easy all-in-one access point that provides a full view of options and costs, CCA members have the ability to acquire the benefits that produce peace of mind for themselves and their families. CCA members and their employees can choose life, long-term disability, professional overhead expense, AD&D, critical illness, and health & dental coverage, as well as the specific amount they need.

CHAMPION PROFILE


Statue in the Oslo sculpture park, displaying the works of Gustav Vigeland

BACK TO BASICSA report on the International Back and Neck Pain Research Forum 2017

By Dr. Simon French, BAppSc (Chiropractic), MPH, PhD

RESEARCH FEATURE


The International Back and Neck Pain Research Forum is one of the premier international research conferences where current research relevant to the primary care management of back and neck pain is presented. The conference occurs every 18 months to two years, and this year it was held in the lovely setting of Oslo, Norway.

I have been attending this conference since 2006 and I have only missed one during that time. The conference is attended by a relatively small group of collaborative researchers (approximately 200) who spend their days thinking and attempting to address the complexity of low back and neck pain with an aim to reduce their burden on individuals and the community. I remember the first back pain research Forum (“Forum”) I attended as a PhD student was held in Amsterdam. I took my seat and looked around the room at the other delegates. I was struck that almost everyone sitting in the audience could easily hold their place as a keynote speaker at a chiropractic clinical conference. A daunting experience for a PhD student! But I soon learned that this group of people were collaborative, kind, generous, and willing to share and debate their knowledge and thoughts about research in this area.

The conference theme this year was “Back to Basics,” with a promise to give delegates the opportunity to reflect on recent and current research activities and give direction to future research. The conference was meant to embrace basic questions from different perspectives; from researchers, clinicians, and from the patients who experience back and/or neck pain.

The opening session by Dr. Chris Maher, from the University of Sydney in Australia, was an intentionally provocative talk from one of the world’s leading back pain researchers. Dr. Maher asked the audience to think about what were the basic questions in back and neck pain research in primary care that have not yet been answered. He highlighted the huge burden of these conditions but contrasted that with the very small amount of research funding that is allocated to these conditions. For example, in Australia, only approximately one percent of government research funds are allocated to musculoskeletal research. He then discussed the following thought-provoking topics: the limited evidence behind red flag screening; the conflicting recommendations in international back pain guidelines for

treatments like acetaminophen and stratified care approaches; the lack of research for dose reduction strategies for people who take opioids for pain; low-value care (e.g., the overuse of imaging for back pain); and that these problems exist in both high and low-income countries.

A highlight for me was the session “What are patients’ basic needs and questions?” This session included comments from a patient’s perspective (Dr. Henrik Sinding-Larsen from the University of Oslo in Norway), who was a previous leader of the Norwegian Back Pain Association. He discussed his experience with back pain, focusing on negative comments he had received from healthcare practitioners including being told he had

“irrational fear avoidance” problems. He urged clinicians and researchers to change their attitude because in his experience with multiple healthcare providers, if a treatment did not work, rather than question the hypothesis, practitioners tend to think there is something wrong with the patient.

This session also included comments by Dr. Rachelle Buchbinder from Monash University in Melbourne, Australia, who gave an overview of the research into the clinician–patient relationships and patients’ needs. She said that research has demonstrated that contextual factors—and how clinicians relate, listen, and show concern and empathy—are important considerations in providing a healthy clinician–patient relationship.

Dr. Simon French, along with a number of other Canadian chiropractic researchers, recently attended the International Back and Neck Pain Research Forum 2017 in Oslo, Norway. Dr. French gives his thoughts on the conference and reflections on the current state of affairs in back pain research.

Oslo Opera House, home to the Norwegian National Opera & Ballet


Other major themes explored in the conference were technology and back pain (how information technology and primary care can work together), placebo/contextual effects, risk stratification approaches (i.e., targeting people with different treatments depending on their risk profile; shows early promise but increasing number of studies showing challenges), and twin studies and genetic influences on back pain.

A highlight for many was from Canada’s very own Dr. Jill Hayden, who presented the results of her

Conference venue, Gamle Logen, or the old Masonic lodge, built

for the Freemasons in 1836

“Research has demonstrated that contextual factors—and how clinicians relate, listen, and show concern and empathy—are important considerations in providing a healthy clinician–patient relationship.”

RESEARCH FEATURE


soon-to-be-published Cochrane Review regarding exercise for chronic back pain. The review will include more than 200 randomized trials for back pain and is the single type of treatment that has been subjected to the most randomized trials in the field of low back pain research. The review’s findings were that exercise was (still, like the original review) effective with a statistically significant effect for pain and function, but with only minimal clinical significance. Dr. Hayden’s talk enabled a lively discussion among the delegates, both in the auditorium and over the remaining days of the conference, about the ongoing relevance of systematic reviews and the need for large, high-quality trials when examining treatments.

Many attendees were in awe at the sheer volume of work, but there were also many different interpretations of the data. In the summing-up session, delegates were encouraged to use this review to debate and explore the evidence and its interpretation, and with some delegates calling for a moratorium on small sample-sized exercise trials in this area.

A number of other Canadian chiropractic researchers featured at the conference and presented their research. These included Dr. Carlo Ammendolia, Dr. Greg Kawchuk, and Dr. André Bussières, who all presented their research in various forums, either as a presentation on stage, by giving a poster presentation, or in a research workshop.

In the closing session, Dr. Bart Koes from ErasmusMC in The Netherlands, the Chair of the Forum’s International Organising Committee, gave his impression of the current state of back pain

research and how far it has come over the last 20 years. He noted that guideline recommendations over this time, informed by research that has been presented in this Forum, have changed in the following ways: they have moved from recommending passive to more active treatments; recommending non-pharmacological care before pharmacological care; changing from advice to bed rest to advice to stay active; changing from a focus on pain to a focus on function; changing from advising sick leave to advising early return to work; changing from “one size fits all” approach to (at least initial success) with stratified care approaches; and finally, accepting that clinical approaches involve some “placebo” or non-specific effects, with recommendations to optimize these non-specific effects.

Overall, from my perspective, the quality of research presented was perhaps the highest quality I have ever seen at this Forum. It was an encouraging sign for the future of this body of research to see the large number of young researchers who presented their findings. Overall, there was much discussion about where, on the one hand, there does not appear to be that much progress in improving back pain outcomes, but on the other hand, this Forum also highlighted several areas where there is hope for developing new strategies to reduce the huge burden of back pain.

The next Forum will be held in Quebec City in July 2019

Thank you to Dr. Carlo Ammendolia, Dr. André Bussières, and Dr. Elisabeth Angier

for contributing their thoughts on the conference for this article.

Oslo City Hall, the location of conference reception, houses the Oslo City Council and the city's administration. This is where the Nobel Peace Prize ceremony takes place every year in December

“In this researcher’s experience with multiple healthcare providers, if a treatment did not work, rather than question the hypothesis, practitioners tend to think there is something wrong with the patient.”


THE PAIN TRIALSExploring the latest developments in the management of degenerative lumbar spinal stenosis

By Carlo Ammendolia, DC, PhDCCRF Research Chair, Mount Sinai Hospital, University of Toronto

RESEARCH FEATURE


W ith the upcoming National Convention and Tradeshow theme being “Pain”—or, “A Better Approach to Pain Management, Chiropractic Care Changes Pain”—it’s appropriate that we talk about pain from different angles. Pain is real, complex, and can be difficult to manage.

Currently, a large facet of my research focuses on pain connected to degenerative lumbar spinal stenosis (DLSS).

The overall goals of this research are to provide chiropractors and other healthcare practitioners with a better understanding of DLSS and to develop and test interventions that will maximize functional status and reduce the risk of disability in this patient population. These interventions should be evidence-based and have the ability to be practically applied in daily practice. With the Boot Camp Program, we feel we have been successful in achieving these goals.

The Boot Camp Program for Spinal Stenosis© is an evidence-based, non-surgical approach to managing DLSS developed at Mount Sinai Hospital in Toronto. Preliminary test results of the program were impressive, and have been instrumental in securing the funding of two randomized clinical trials at the University of Pittsburgh and the University of Toronto.

We have also developed boot camp programs for sciatica, persistent neck and back pain, ankylosing spondylitis, knee and hip osteoarthritis, persistent shoulder pain, and fibromyalgia.

At the upcoming National Convention and Tradeshow, a hands-on workshop will be conducted on the Boot Camp Program for lumbar spinal stenosis for attending chiropractors who will learn how to implement the program in their clinics.

CLINICAL DEFINITIONS OF DLSSDLSS is a leading cause of pain, disability, and loss of independence in older adults. It is defined as a focal narrowing of the central canal and/or lateral foramina of the spine usually caused by age-related degenerative changes such as thickening of the facet joints, folding of the ligamentum flavum, and thinning and bulging discs.

Neurogenic claudication is the term used to describe the clinical syndrome caused by DLSS. It is characterized by bilateral or unilateral buttock, lower extremity pain, heaviness, numbness, tingling, or weakness, precipitated by walking and standing and relieved by sitting and bending forward (the shopping cart sign). The symptoms of neurogenic claudication are due to a lack of blood flow to the spinal nerves (neural ischemia) as a consequence of the narrowed canals. Changing posture changes the size of the canals and impacts blood flow to the spinal nerves.

IMPACTIn terms of treatment, lumbar spinal stenosis is the most common reason for spine surgery in people over the age of 65. With respect to nonsurgical treatment, there have been a number of systematic reviews published over the past 10 years and all come to the same conclusion: that all non-surgical treatment for lumbar spinal stenosis have unproven scientific benefits.

Limited walking ability is the dominant functional impairment caused by DLSS. Inability to walk among individuals with DLSS leads to a sedentary lifestyle and a progressive decline in health status. DLSS is a chronic disease that can deteriorate and is associated with high levels of depression, anxiety, and hopelessness that further perpetuates disability.

Participants enjoy the interactive and hands-on training of the Boot Camp program at our workshops


Reliable data on the prevalence of symptomatic DLSS is lacking. In Japan, it is estimated that 10% of the population, or over 12 million people, currently suffer from DLSS. In Canada, in the next 15 years, 25% of the population will be over the age of 65, of whom one-third are expected to develop DLSS. This will result in a significant burden to the individuals and to the healthcare system.

OUR RESEARCHWe have developed a comprehensive conservative treatment approach for lumbar spinal stenosis that is directed to the physical, psychological, and functional aspects of this condition with a goal of maximizing walking ability and reducing the risk of further disability. This program is known as the Boot Camp Program for Spinal Stenosis©. It is a six-week program that involves education, specific manual therapy techniques, condition-specific home-based exercises, and instructions on self-management strategies. A key self-management strategy is training patients how to reduce the lumbar lordosis when standing and walking to increase the cross-sectional area of the lumbar spine and reduce lower extremity symptoms. The program is designed to be maintained for life since there is no cure for lumbar spinal stenosis. In an award-winning study published in the Journal of Manipulative and Physiological Therapeutics, we reported the results of 49 patients with DLSS who completed the Boot Camp program. In this study we examined pre-and post-disability scores, leg and low back pain scores, walking ability, symptom intensity, overall function, and satisfaction with care. All these outcomes demonstrated both statistical and clinically important improvements following the Boot Camp program. We have just completed a follow-up study (unpublished) where we followed these same patients over an average of 3.3 years and reassessed the same outcomes. What we found was quite compelling in that all outcomes measured, except for back pain, had maintained their initial improvements.

We also just completed two randomized control trials, one at the University Toronto (the University of Toronto Spinal Stenosis Study) and the other at the University of Pittsburgh (funded by the Affordable Care Act) that further evaluated the Boot Camp program. The University of Toronto Spinal Stenosis study randomized 104 patients to either the Boot Camp program or self-directed care. Self-directed care involved one education

session with a chiropractor. Both groups received a patient workbook and educational video that described all the required exercises and self-management strategies. Both groups also received a pedometer and with instructions how to monitor their walking ability on a weekly basis. The main outcome was objective walking ability measured by the Self-Paced Walk Test, which is a test that measures the distance walked in 30 minutes. Follow-up measures

were conducted at 8 weeks, 3 months, 6 months, and 12 months following randomization. The results again were very compelling with a very large mean improvement in walking ability (over half a kilometre improvement in walking distance in 30 minutes) at 8 weeks among Boot Camp participants. More surprising was that even greater improvements in walking ability were seen at 6-month and 12-month follow-ups. In comparison, the mean improvement in the in the self-directed group was approximately 200 metres, and this remained flat over the remaining follow-up periods. This study has been submitted for publication and will be available to the public in the next several months.

The University of Pittsburgh study compared the Boot Camp program to usual care provided by a physical medicine specialist and to community-based exercise performed at a local senior’s community centre. At 8 weeks, the Boot Camp program participants had significantly better reduction in symptoms compared to the treatment received by the physical medicine specialists or among participants who attended community-based exercise. Moreover, the proportion of participants that showed clinically important improvements in walking ability was superior among participants in the Boot Camp program compared to the other two groups. The result of this study has also been submitted for publication and should also be available to the public in the next several months.

We also have conducted a randomized control trial examining the use of a transcutaneous electrical nerve stimulation (TENS) machine while walking compared to placebo TENS. Animal studies conducted by Dr. Brian Budgell at CMCC showed that electrical stimulation of the skin around the area of spinal stenosis could improve blood flow to the spinal nerves. The rationale for this study was that perhaps TENS could improve blood flow to the spinal nerves in patients with DLSS. Preliminary results suggest that placebo TENS machine and the active TENS machine both improve walking ability. In another randomized control trial, we examined the benefit of a prototype spinal stenosis belt compared to a regular lumbosacral belt in improving walking ability. The goal of spinal stenosis belt was to alter the spinal alignment while walking to maximize the cross-sectional area of the lumbar spine and to improve blood flow to the spinal nerves. Preliminary results of this study suggested that both belts improve walking ability. Details of the results of these two randomized control trials will be submitted for publication soon.

When the profession is equipped with the foremost research, we have the ability to press further for recognition in national healthcare forums.

RESEARCH FEATURE


Call 1.800.234.6922 or visit nycc.edu.

Dedicated to: • Academic Excellence• Quality Patient Care• Professional Leadership

Degree Programs include: • Doctor of Chiropractic• Master of Science in Acupuncture• Master of Science in Acupuncture and Oriental Medicine• Master of Science in Applied Clinical Nutrition

(online delivery)• Master of Science in Human Anatomy & Physiology

Instruction (online delivery)

Academic Excellence. Professional Success. 2360 ROUTE 89 • SENECA FALLS, NY 13148

NEARLY 20% OF OUR STUDENTS HAIL FROM CANADA

RECOGNITIONThis year we published a study in the Journal of the Canadian Chiropractic Association that looked at the physical, psychological, and functional impact of patients who have degenerative lumbar spinal stenosis. In this study, we interviewed 15 patients who have received nonsurgical care at the chiropractic spine clinic at Mount Sinai Hospital and 13 patients receiving surgical care at Toronto Western Hospital. Data were collected using telephone interviews by a trained researcher. Our goal was to get a personal patient’s perspective on what it is like to live with DLSS. The results of this qualitative study showed that DLSS has a multidimensional impact on patients. We found that pain and limited walking and standing ability were the most bothersome aspects of DLSS that significantly impacted important activities of daily living, as well as meaningful recreational and social activities.

This study was one of the first to qualitatively identify the significant emotional impact of DLSS. This is a finding that should not be overlooked in clinical practice and future research. A holistic understanding of how psychosocial and other factors impact outcomes in this population is needed. We also present a conceptual model of potential interactions between important outcomes in DLSS as a framework for future study.

RESEARCH SHOWCASEIt is no surprise that the theme for the 2018 CCA National Convention and Tradeshow (which is happening from April 27–29, 2018, in Calgary, Alberta) is “A Better Approach to Pain Management—Chiropractic Care changes Pain.” It aims to support and facilitate progressive and innovative practices in patient care in the areas of prevention, assessment, diagnosis and management of acute and chronic musculoskeletal conditions.

We believe in the Boot Camp benefits and want to showcase this leading development in research. That is why, on the Friday of the convention (April 27, 2018), we will offer a full day certification of the Boot Camp Program for Lumbar Spinal Stenosis©.

Pain is complex. Millions of Canadians suffer from persistent back pain, neck pain, migraines, and headaches. Chronic pain can significantly impact an individual’s ability to carry out daily activities, work productively, and maintain family commitments.

We believe in the power of research. We believe in helping patients and treating pain. When it comes to pain, we know where chiropractors stand. When the profession is equipped with the foremost research, we have the ability to press further for recognition in national healthcare forums. Now is your chance to engage with what this new research development has to offer.


OUTREACH

Chiropractic care in the Dominican RepublicBY DR. ADRIAN CHOW, DC AND DR. JULIE YAWORSKI, DC

E very year, the Canadian Memorial Chiropractic College organizes a chiropractic outreach initiative to work with the underserviced populations in the Dominican Republic. This year, our team consisted of 12 fourth-year interns (now DCs)—including ourselves, Carly Mattson, Brandon Jilesen, Ryan Albert, Cristina Leonardelli, Amanda Huang, Daphne To, Nader Abdelkader, Tomasz Kowal, Gloria Cheung, and Lauren Quattrocchi—under the guidance and leadership of Dr. Patricia Tavares and Dr. Leslie Wiltshire. From Santo Domingo, we travelled to Dajabon to begin 12 days of care throughout the Dominican Republic. We treated in Loma de Cabrera, Partido, Gaspar Hernandez, Verangua, Joba Arriba, Moca, and Canca La Reina.

One of the first experiences that set the tone for the trip was pulling up to our first treating location, stepping off of the bus and rounding the corner to see hundreds of people lined up waiting to see us. Chaos was what we named it. We quickly learned that chaos would become the norm and we figured out a way to work with the chaos rather than against it. We unloaded our tables and supplies and quickly set up in two classrooms. After a crash

course in common Spanish words such as dolor (pain), we each took a patient and went promptly into action. We soon developed a systematic routine for each patient: identifying the area of chief complaint, working with the translators to identify red flags, and ultimately, through the history taking and physical examination of each patient, determining whether the pain was musculoskeletal in nature. At the end of the treatment, we recommended some exercises and advice to our patients on how to better manage their pain. The transition from verbal language as the primary means of communication to using gestures and body language wasn’t effortless, but the transition came sooner than expected. A smile, a grimace, or even a gesture of gratitude were actions that did not require translation. Actions served as our universal language and helped us connect with our patients.

What we learned on a very personal level is that pain knows no language. Pain is something that we, as chiropractors, understand and everyone has experienced it at some point in their lives. For those 12 days, we were surrounded by pain. The people of the Dominican Republic who came to our treating locations would come with all kinds of pain; pain they had for 20 years, pain that started last week, deep pain, sharp pain, and pain they did

PAIN KNOWS NO LANGUAGE

Fourth-year intern Adrian Chow (now graduated) taking clinic notes at the CMCC chiropractic outreach clinic in the Dominican Republic


not understand. We were faced with a variety of conditions and incidents that brought about their pain, including motorcycle accidents, falls, and complications from medical conditions such as diabetes and hypertension. What we had to remember was the scope of what we could help with and remind ourselves that part of our role was not only treating musculoskeletal complaints but recognizing when a patient needed continued care or hospitalization. This outreach was an opportunity to apply the last three years of education and one-year clinical internship to critical use. We experienced first-hand that there are many different ways to put the pain puzzle together.

Over the duration of 12 days, we saw and treated over 1,100 patients. One of the things that will stay with us from this experience was the gratitude the patients had for the time we spent with them. It was amazing to see the immediate relief many patients experienced from our treatments and to see how excited they were to try the exercises and stretches. When practising in such remote locations, our only treatment tools were our hands and whatever knowledge we brought with us. Through this experience, we witnessed how powerful simple tools are and what they can accomplish.

A consequence of our short stay is that we may never know what will happen to these individuals or be able to provide them with continued care. What we were able to do was bring musculoskeletal care to another part of the world where there is limited access.

We are incredibly grateful to have had the privilege to represent the CMCC and the chiropractic profession in the Dominican Republic. An experience such as this is invaluable for interns to apply clinical reasoning in an environment different from their own, for patients who may never have experienced musculoskeletal care before. Amongst the chaos, we gained an increased appreciation of the care we can provide with just our hands and are looking forward to being able to utilize this experience to best serve our future patients.

Front row (left to right): Dr. Pat Tavares and interns Lauren Quattrocchi, Julie Yaworski, Carly Mattson, Daphne To, and Amanda HuangMiddle row (left to right): Interns Tomasz Kowal, Cristina Leonardelli, Gloria Cheung, Adrian Chow, Brandon Jilesen, and Dr. Les WiltshireBack row (left to right): Interns Ryan Albert and Nader Abdelkader Note: All interns have now graduated and are currently doctors of chiropractic

Fourth-year intern Julie Yaworski (now graduated) treating a patient


ADVOCACY

MICHAEL HEITSHU DIRECTOR OF PUBLIC AFFAIRS

L ast year, 19 million opioid prescriptions were written in Canada.1 Even though there is a growing awareness of the risks of opioid use, opioid prescribing, addiction, and death all continue to increase.

North Americans consume a disproportionate amount of the world’s prescription opioids. Many Canadians that are taking opioids as directed will become dependent and as many as one in eight Canadians taking an opioid for chronic pain will become addicted.2 Even a majority of illicit opioid users were first introduced through legitimate prescription.

The CCA is now a recognized leader in efforts to solve this crisis. Our leadership began with a simple truth: back pain and other musculoskeletal (MSK) conditions are the leading reason for opioid prescribing. In other words, in many ways, the opioid crisis is a back pain crisis.

A second important truth is that opioids are not effective over the long term, and of course are associated with tremendous risks. Safer and more effective approaches are needed to manage acute and chronic pain in Canada and reduce reliance on opioids as a first-line intervention.

It is worth taking a step back to look at how the CCA has become a leading voice in efforts to address the opioid crisis. About four years ago, we began to lay plans for an MSK strategy for chiropractors to be leading advocates for the MSK health of Canadians. This included building an understanding of the burden of MSK conditions and carving out space for chiropractors as the MSK experts in the healthcare system. After all, if there is no understanding of the problem, it is difficult to talk about solutions.

The CCA began raising concerns about the opioid crisis starting in the spring of last year. We used almost every opportunity to engage with the federal Minister of Health (then Minister Jane Philpott), her officials, and other stakeholders to take a broader perspective on the opioid crisis, particularly to be looking upstream to understand what the federal government can be doing to reduce the prevalence of opioid prescribing.

It would have been a far more difficult a path to success if we had not invested upfront in building a strong evidence case. Our primary focus was not on the risks of opioids because others were making this case. Instead, we assembled the best evidence about the central role of MSK pain in driving opioid prescribing, the importance of prioritizing conservative care as an alternative, and essential steps that must be taken to reduce barriers to the integration of and access to chiropractic care. The CCA White Paper titled “A Better Approach to Pain Management: Responding to Canada’s Opioid Crisis”3 gave us credibility. It highlighted our commitment to raising awareness of the underlying causes of this crisis and our seriousness in being part of the solution while serving as a resource we could refer back to over and over when making our case.

The result of these efforts is that chiropractors became one of only five health professions invited by Health Canada to be part of the federal government’s original opioid strategy.4 Our commitment as part of the federal strategy is to provide prescribing professionals with guidance on the appropriate triage and referral of patients with acute and chronic MSK-related pain. This recognition of the value of chiropractic care in this arena is a major accomplishment.

The National Advisory Committee was established to develop these practice recommendations for both prescribing professions

RESPONDING TO THE OPIOID CRISISChanging the conversation about pain management


and chiropractors. The committee is completing the document’s final development and dissemination efforts will begin this Fall.

An important support for these dissemination efforts is Canada’s new guideline for opioid prescribing. The 2017 Canadian Guidelines for Opioids for Chronic Pain5 were developed by a national pain centre working group chaired by chiropractic researcher Dr. Jason Busse. The first and stro

Documents

BACK Issue 14 MATTERS - Canadian Chiropractic Association · 2017-12-07 · Issue 14 Canadian Chiropractic Association 2017 1. BACK MATTERS. Issue 14. News and Views for Canada’s