Circling Care Around Patients

An informed and cross-functional interprofessional team is the key tool for organizing and coordinating effective care plans and services to meet the needs of your patients with often complex and complicated health needs1. This fact becomes especially true in the diagnosis and ongoing care of over 2.4 million Ontarians2 currently suffering from the chronic disease of arthritis. Interprofessional teams combine the expertise and skills of various professionals, like chiropractors to assess their patient’s needs and therapeutic requirements when controlling this debilitating disease.

Chiropractic treatment is used to diminish various muscle, joint, and spinal conditions and focuses on Musculoskeletal structure; such as degenerative disc/joint disease, rheumatoid arthritis, ankylosing spondylitis, spinal stenosis, spondyloarthropathies, and radiculopathies secondary to disc herniations (sometimes called “sciatica”). By engaging manual therapies and exercises, education, and self-management strategies, your patients can better manage their condition.

As you know, an important part of the circle of care when dealing with a chronic condition like arthritis is helping your patients make life more manageable with mobility and activity. Chiropractors also provide other coping strategies, such as mindfulness meditation and guided imagery, to help patients manage the stress and anxiety that can come with their diagnosis.
The Ontario Medical Association (OMA) understands the importance of a team-based and collaborative health care team as detailed in their recent report, “Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care”3.

A growing number of patients are asking their medical doctors to include chiropractors in their circle of care. Coordinating successful care plans and treatments can help improve the outcomes of patients with complex arthritis care needs.

Team-based and Collaborative Care

“Patients do better when they have a team of care providers… Where these teams exist, patients have faster and easier access to specific care they need so are healthier, have fewer hospital admissions and are more satisfied. System costs are also reduced.” 

Once diagnosed by chiropractors, their patients are introduced to a multitude of recommendations and challenges as they desperately try to manage their condition. Chiropractors are here to support the medical community by offering medical doctors and specialists a collaborative pathway with applicable diagnoses and further caring regimens and modalities for their arthritis patients.

Four Key Reasons to Include a Chiropractor – from Dr. Aksa Ahmed, DC.

According to one of our leading arthritis chiropractors, Dr. Aksa Ahmed, DC, of the Rebecca MacDonald Centre for Arthritis & Autoimmune Disease at Mount Sinai Hospital in Toronto, the need for chiropractic care is an integral part of the patient care planning when diagnosing and helping to manage one in six Canadians1 currently suffering from this debilitating disease.

Dr. Ahmed is also the Research Coordinator for the University of Toronto’s Lumbar Spinal Stenosis Study at Mount Sinai Hospital. She identified the following key areas of “why it’s essential chiropractors are part of the circle of care for patients with arthritis’ when managing and diagnosing arthritis.”

Dr. Aksa Ahmed, DC

1. Giving patients hope by working together.

For many individuals with arthritis, there may be long intervals between the onset of symptoms, managing of those symptoms, timing of the diagnosis, and the eventual recovery of lost functional ability.

Patients will routinely exhaust all avenues of care prior to seeing, or even considering a chiropractor.

It should not have to be like this.

Research has shown us, when patients with arthritis seek early intervention, maintain an active lifestyle with regular exercise, and learn to self-manage their pain, there is a significant improvement.  This increases the individual’s overall ability to carry out functional activities as part of their daily living routines4.

By incorporating chiropractors within the circle of care, patients will have the support they need in this often-lengthy journey rather than considering chiropractic as an alternate care option.

I probably had 40 to 50 appointments, almost everybody. The most useful part I found of working with a chiropractor as part of my circle of care, was knowing what to do when you’re not where you need to be when trying to get help.”

David Rennick, Ankylosing Spondylitis Patient

2. We have the clinical expertise and knowledge.

Chiropractic care is a patient-centered, non-invasive, hands-on, regulated health care profession focused on the neuromusculoskeletal (nMSK) system.

Chiropractors use the best available evidence and clinical expertise to diagnose issues that affect the body’s movement, including back and neck pain and pain associated with arthritis. They are trained to treat the pain and functional limitations associated with arthritis through modalities such as manual therapy and therapeutic exercise prescription; All are part of their chiropractic curriculum at the Canadian Memorial Chiropractic College (CMCC).

As part of the Doctor of Chiropractic (DC) program at CMCC, DCs will graduate with a total of 4,485 class hours. This includes 1,405 hours of medical clerkship, culminating in seven years of education and medical student practice.

A chiropractor’s training is ongoing. Increasing years of practice will enable an opportunity to learn new clinical practices. Chiropractors participate in ongoing continuing education through attending seminars, rounds and completing additional training.

Recommendations for osteoarthritis management - table

Table: Recommendations for physical, psychosocial, and mind-body approaches for the management of osteoarthritis of the hand, knee, and hip

Click/tap on the image (left) to view in full size.  Once the table opens in a new window, you can download it by right-clicking and selecting “save image as” from the dropdown menu.

“If you have back or neck pain due to osteoarthritis, chiropractic is one of the safest therapies you can use.”

Scott Haldeman, MD, Chairman Emeritus of the Research Council for the World Federation of Chiropractic

“If a person is experiencing a flare-up in their knee causing pain associated with walking, there may be secondary pain in the lower back. This is where chiropractors will be able to reduce the pain level in this region making their daily activity more manageable.

Dr. Amy Brown, DC

3. Collaborating with our allied health professionals.

I practise in an outpatient chiropractic clinic in the Rheumatology Department at Mount Sinai Hospital in Toronto. My area of focus is spine, muscle and joint care for individuals living with arthritis. The clinic where I work contains many medical doctors including rheumatologists, neurologists, and other health care professionals.

It’s invaluable to have access to one another’s expertise. We each bring different specializations, knowledge, backgrounds, and skills to the table. I strongly believe this collaborative approach is the future of health care. It’s what allows us to provide truly optimal patient care.

“To work effectively together, team members must possess specific knowledge, skills, and attitudes such as the ability to monitor each other’s performance, knowledge of their own and teammate’s responsibilities, and a positive disposition toward working in a team.” 

Lisa Lockhart, MHA, MSN, RN, NE-BC

4. A case for support.

Very recently I saw a 28-year-old male patient in the clinic who was referred from Mount Sinai’s emergency department for a sudden onset of low back pain without neurological symptoms. His pain was severely impacting his ability to sit, stand, walk and work. A thorough assessment revealed that this was not his first episode of debilitating low back pain and he often experienced considerable morning stiffness lasting hours. This discovery was coupled with a significant family history of inflammatory arthritis. I came up with a suitable plan of management, accompanied by a note to his family doctor for further investigation. In turn, the doctor ordered an inflammatory panel of bloodwork while I worked closely with the patient to decrease his pain and improve his function.

After a few sessions of chiropractic treatment consisting of a combination of manual therapy and therapeutic exercise prescription, the patient had regained much of his lost functional ability. He had also learned self-management strategies should he experience future bouts of acute aggravation. His bloodwork results came back elevated for some of the inflammatory markers and his family doctor referred him to a rheumatologist. I believe this to be a fine example of how a strong interprofessional team of health care providers can help facilitate care for arthritis patients.

“Without access to other programs as the spinal stenosis program, I believe I would have ended up incapacitated and depressed and gradually needing extended care.

Jane Marsland, Spinal Stenosis Patient

“I have a lot of hope chiropractic care will be more easily accessed. There’s a lot of opportunity to make it an easier experience for people that are coming down the same care journey, just years into the future.”

David Rennick, Ankylosing Spondylitis Patient

Interprofessional Evidence

Dr. Jasleen Singh working with patient
Dr. Jasleen Singh, DC
working with a patient

Often patients who have chronic conditions, illnesses, or injuries, also have nMSK challenges. These challenges add to their pain and limit their mobility. For these patients, an interprofessional collaborative approach works particularly well5.

As part of your patient’s interprofessional team, chiropractors are qualified to assess, diagnose, and treat issues affecting the nMSK system, such as Osteoarthritis (OA), the largest cohort representing all other arthritis conditions combined2,6.

For persons with degenerative arthritis conditions which require referrals to medical doctors for additional diagnostic or lab tests, such as Inflammatory Arthritis (IA) or Rheumatoid Arthritis (RA), chiropractors provide informed referrals to medical doctors and other health care professionals6.

Chiropractors, nurse practitioners and other health care professionals will then collaborate with medical doctors and specialists to support their patients’ ongoing care, as required1.

In 2017, The American College of Physicians released new Guidelines that now support the use of nonpharmacologic therapies, such as chiropractic care and acupuncture, as first-line treatments for low back pain, before using medication7.

Case Studies and Research

A 2013 study published in Osteoarthritis and Cartilage found that patient education combined with 12 chiropractic treatments (twice a week for six weeks) was more effective for hip OA than a daily stretching program or patient education alone 7.

To work effectively together, team members must possess specific knowledge, skills, and attitudes such as the ability to monitor each other’s performance, knowledge of their own and teammate’s responsibilities, and a positive disposition toward working in a team8.

Below, research and case studies that provide evidence to chiropractic care, or as termed in many articles as exercise, physical therapy, or manual therapy, are in fact referring to forms of treatment. Evidence-based chiropractic treatment consists of a combination of manual therapy, therapeutic exercise prescription, and/or patient education/self-management strategies.

Rheumatoid Arthritis

Johns Hopkins Arthritis Centre: rehabilitation management for rheumatoid arthritis patients.

American College of Rheumatology: Regular low-impact exercises, such as walking, and exercises can increase muscle strength. This will improve your overall health and lower pressure on your joints.

Physical Therapy

Mayo Clinic: Exercise helps ease pain and stiffness. Mayo Clinic: Not-for-profit organization committed to clinical practice, education and research, providing expert whole-person care to everyone who needs healing. exercise helps ease arthritis pain and stiffness.

Clinical and Experimental Rheumatology: Skou and Roos. 2019. Physical therapy for patients with knee and hip osteoarthritis: supervised, active treatment is current best practice.

Circle it: A discussion on how chiropractors can support a patient’s arthritis care

Patients suffering from chronic arthritis pain expect collaborative care from their health care professionals. In this Facebook Live event (October 14, 2021), Dave Rennick, a patient with inflammatory arthritis, joined chiropractor Dr. Amy Brown for a revealing and personal discussion about his journey from chronic pain back to living a productive and active lifestyle.

[1]Social Care Institute for Excellence, Integrated Research and Practice – Multidisciplinary Teams.
[2] Arthritis Society (ACREU). (2019). The Status of Arthritis in Canada. National Report.
[3] Ontario Medical Association. Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care.
[4] The American College of Rheumatology. (2021). Arthritis Treatment. Mending Through Movement (online course – expires Dec. 31, 2021).
[5] CMCC Research Report 2018-20, A selection of published research by CMCC faculty.
[6] Sharon L. Kolasinki, Tuhina Neogi, et. al., 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.
[7] American College of Physicians. (2017). American College of Physicians issues guideline for treating nonradicular low back pain.
[8] Nancrow, S. A., Smith, T., Ariss, S. and Enderby, P. (2015). Qualitative evaluation of the implementation of the interdisciplinary management tool: a reflective tool to enhance interdisciplinary teamwork using structured, facilitated action research for implementation.