The importance of musculoskeletal health problems Up to 30% of all GP consultations relate to musculoskeletal problems, and this area accounts for a £230m yearly burden on the health economy. This is dwarfed, however, by the impact on the wider economy – each year neck and back pain lead to nearly 11 million sick days off for workers in England. (

NICE low back pain guidance - outline Guidance for early treatment and management of persistent or recurrent low back pain, defined as non-specific low back pain that has lasted for more than 6 weeks, but for less than 12 months

NICE low back pain guidance - principles of management Keep diagnosis under review at all times Promote self-management Offer drug treatments as appropriate Offer one of the following treatment options ….

Treatment options Exercise programme Course of manual therapy Course of acupuncture

Manual therapy To include spinal manipulation Up to 9 sessions over up to 12 weeks Care can be delivered by: Chiropractors Osteopaths Physiotherapists with postgraduate training in manipulation

What is chiropractic? Chiropractic is a profession, not a treatment Chiropractors provide a package of care including biopsychosocial assessment Chiropractors take a detailed case history and perform a thorough diagnostic examination, which considers all aspects of the presenting complaint Package of care may include physical treatments drawn from all types of manual therapy as well as spinal manipulation, exercise, muscular therapies and a range of advice on activity, lifestyle and prevention

The chiropractic profession Chiropractors Act (1994) Statutory regulation (GCC) with mandatory CPD The Royal College of Chiropractors (2012)

Case Study: Manual Therapies Back and Neck Service - NHS North East Essex ( NHS North East Essex wanted to provide greater choice, easier access and shorter waiting times for patients suffering back and neck pain and at the same time address the unsustainably high demand on local spinal services In 2008, all existing providers were contacted and invited to bid to offer patients these services Patients chose from 20 different providers of chiropractic, osteopathy and physiotherapy based throughout the Colchester and Tendering area. There were four chiropractic, five osteopathy and 11 physiotherapy providers to choose from and they all meet NHS standards and agreed prices. Patients were given an appointment within two weeks and received up to four treatments

NHS North East Essex: Outcomes During 2009/10, 2,810 patients used these services and 97% of patients were seen within two weeks of referral Providers work to locally agreed common referral and clinical protocols and whilst there is competition, there is also cooperation between individual providers and disciplines to ensure service integration for patients

NHS North East Essex: Outcomes Evaluation after the first 12 months of offering patients a choice of any qualified provider has identified improved patient access and choice meaning early treatment and improved outcomes; and reduced primary care consultations, imaging, medication costs and inappropriate referrals to secondary care. Referrals to spinal surgeons have reduced by more than 25%. In 2009, this approach to offering chiropractic, osteopathy and physiotherapy services to treat back and neck conditions was awarded the NHS Alliance ‘Acorn Award’ for alternative therapy A similar service continues under the Any Qualified Provide (AQP) model

Chiropractors don’t only treat back pain Although the evidence for back pain is the most compelling, the following are conditions that chiropractors routinely encounter and treat, and for which RCT evidence indicates effectiveness of chiropractic care: Cervicogenic dizziness Cervicogenic headache Frozen shoulder (adhesive capsulitis Hip osteoarthritis Knee osteoarthritis Migraine headache Patellofemoral pain syndrome Plantar fasciitis Sciatica / radiating leg pain Shoulder girdle pain / dysfunction Tennis elbow (Bronfort et al, 2010: