Health Policy Bulletins

1st August 2019: New Chiropractic Quality Standard for Osteoporosis

The Royal College of Chiropractors’ Health Policy Unit is pleased to announce the publication of a new quality standard which covers the chiropractic assessment and management of patients with osteoporosis and those at risk of osteoporotic fracture.

This quality standard is specific to the environment in which chiropractic care is provided; a setting that is often less constrained by time and resource limitations than other healthcare settings, and where the physical nature of some therapeutic interventions means that understanding a patient’s bone health is of particular importance. Patients present to chiropractors with a wide range of different complaints and (whether or not related to their presenting condition) the presence of osteoporosis, an osteoporotic fracture or major risk factors of osteoporosis should be a consideration.

Chiropractors have the skills and competencies to identify those patients with significant risk factors prior to the potential deterioration in bone density, and to provide early preventative support and advice. Fractures due to osteoporosis are a significant and growing public health concern and chiropractors are well-placed to identify those at risk, support them to make the necessary lifestyle and practical changes to help limit that risk, and to make appropriate referrals for further investigations and management. This embraces best practice in relation to the public health responsibilities of primary healthcare practitioners.

Vertebral fractures are the most common osteoporotic fracture although up to 70% do not come to medical attention and thus remain undiagnosed. Patients with these fractures often present to chiropractors with an increased kyphosis, loss of height and back pain. Given that vertebral fractures are a powerful predictor of further fracture, chiropractors have an important role to play in identifying and managing these patients, including making appropriate referrals, in an attempt to reduce the risk of further fractures.

Due to the prevalence of osteoporosis, increasing numbers of patients that present to chiropractors have already been diagnosed and are taking medications for the condition. Depending on the circumstances, chiropractors may have a multi-disciplinary role to play in co-managing these patients by providing conservative, non-pharmacological care, as well as communicating with the patient’s GP or other healthcare professionals.

Many different patient presentations are associated with osteoporosis, from those who simply have a number of positive risk factors to patients in severe pain having suffered a recent fracture, and the exact management will be different in each case. Therefore, the quality statements that make up the new quality standard are general but, nevertheless, provide achievable markers of high-quality, cost-effective patient care.

The RCC’s Chiropractic Quality Standard for Osteoporosis is available for download here in full and abbreviated versions. A separate copy of the Osteoporosis Assessment and Management Flowchart, which forms part of the full version of the document, is available on the same webpage.

23 May 2019: Suspected neurological conditions: recognition and referral
NICE guideline [NG127]

Published this month, NICE Guideline NG127 covers the initial assessment of symptoms and signs that might indicate a neurological condition. It helps healthcare professionals working in primary and secondary care identify people who should be offered referral for specialist investigation.

The guideline, which gives recommendations for people aged 16 and over, as well as children and young people aged under 16, and includes a helpful interactive flowchart for a wide range of neurological conditions, will provide a useful evidence-based resource for chiropractors.

1 August 2018: Musculoskeletal core capabilities framework for first point of contact practitioners
Released this week, the Musculoskeletal core capabilities framework for first point of contact practitioners is essential reading for chiropractors. Published by NHS England, Health Education England and Skills for Health 2018, the Framework was developed with the Arthritis and Musculoskeletal Alliance (ARMA), of which the RCC is part, and a range of other stakeholders across the whole MSK sector.

The Framework looks at the following key domains within the MSK setting:

A) The Person-Centred Approach
B) Assessment, Investigation and Diagnosis
C) Condition Management, Interventions and Prevention, and
D) Service and Professional Development.

It can be used by practitioners in many ways but, in particular, to review skills, identify training needs and plan continuing professional development.

1 July 2018: New Report – Embedding physical activity in the undergraduate curriculum
All healthcare professionals are well-positioned to influence positive lifestyle changes among their patients, and encouraging physical activity is a vital part of helping patients avoid and manage health problems. However, physical activity is not well integrated into undergraduate curricula for medicine and other healthcare professions.

The ‘Embedding Physical Activity’ report and appendices, co-authored by Ann Gates of Exercise Works who gave a keynote address at the Royal College of Chiropractor’s AGM in January 2018, was commissioned by Public Health England (PHE) & Sport England (SE) as part of their Moving Healthcare Professionals Programme, and is aimed at embedding physical activity into undergraduate curricula. It highlights the initiatives of the Chiropractic Schools and the RCC which are working towards better incorporating physical activity into undergraduate chiropractic training and continuing professional development as part of a wider public health initiative.

14 February 2018: New Public Health Initative
The Royal College of Chiropractors is developing a range of initiatives designed to help chiropractors actively engage with health promotion, with a particular focus on key areas of public health including physical activity, obesity and mental wellbeing.

Dr Mark Gurden, Chair of the RCC Health Policy Unit, commented:

“Chiropractors are well placed to participate in public health initiatives. Collectively, they have several million opportunities every year in the UK to support people in making positive changes to their general health and wellbeing, as well as helping them manage their musculoskeletal health of course.

Our recent AGM & Winter Conference highlighted the RCC’s intentions to encourage chiropractors to engage with a public health agenda and we are now embarking on a programme to:

  • Help chiropractors recognise the importance of their public health role;
  • Help chiropractors enhance their knowledge and skills in providing advice and support to patients in key areas of public health through provision of information, guidance and training;
  • Help chiropractors measure and recognise the impact they can have in key areas of public health.

To take this work forward, we will be exploring the possibility of launching an RCC Public Health Promotion & Wellbeing Society with a view to establishing a new Specialist Faculty in due course.”

31 October 2016: Choosing Wisely – Avoiding wasteful or unnecessary medical tests, treatments and procedures
In 2012, the American Board of Internal Medicine (ABIM) Foundation launched Choosing Wisely, an initiative to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. The initiative has subsequently become global and Choosing Wisely UK was launched last week by the Academy or Medical Royal Colleges. The Academy listed 40 treatments and procedures that are of little or no benefit to patients using recommendations supplied by NICE, and the eleven medical royal colleges that have contributed to date.

The Academy’s list included the recommendation that ‘back pain which is uncomplicated, that is not associated with ‘red flags’ or radicolupathy usually does not require imaging‘. The Royal College of Chiropractors (RCC) is pleased to support this recommendation which concurs with the RCC’s Quality Standards on Acute Low Back Pain and Chronic Low Back Pain.

16 August 2016: New Chronic Pain Quality Standard
The RCC’s Health Policy Unit has developed a new Chiropractic Quality Standard on Chronic Pain, the latest in a series of RCC Quality Standards that aim to make it clear to patients, the public, healthcare professionals, commissioners and chiropractors what high-quality chiropractic care looks like.

The Chronic Pain quality standard can be accessed here along with all the other RCC quality standards. An associated audit toolkit will be available shortly.

Saving costs and improving care through better use of existing manpower resources

The Chartered Society of Physiotherapy has recently called for the NHS to provide direct access to physiotherapy without the need to see a GP first (1).

The Royal College of Chiropractors supports the notion that NHS patients with musculoskeletal conditions should have direct access to skilled and competent health professionals who can assess their needs and provide appropriate care. Chiropractors, regulated health care professionals who already fulfil this role in private practice, have the necessary skills and competencies (2) and are ideally placed to offer this to NHS patients in the community.

Where chiropractors have been commissioned to work in the NHS, the resultant services have proved popular with patients and their GPs and have demonstrated safe, effective and cost-effective care. Indeed, it has been shown that these services have reduced demand on other NHS services potentially reducing overall costs (3).

Chiropractors represent a highly skilled, underutilised workforce and the Royal College of Chiropractors would like to see better utilisation of chiropractors in the NHS to improve patient outcomes and quality of care, and to reduce overall costs.

Chiropractic competencies and skills to manage low back and radicular pain

The RCC’s Health Policy Unit has today published a document outlining the skills and competencies of chiropractors in the context of managing low back and radicular pain. It explains that:

  • Chiropractic is a profession
  • Chiropractors provide a package of care
  • The care provided by chiropractors is effective for range of conditions
  • The role of chiropractors is recognised in NHS England’s Pathfinder pathway of care for low pack and radicular pain
  • Chiropractors have the competencies and skills to manage low back and radicular pain in the community

Similar documents addressing other musculoskeletal conditions are under development, as are CPD opportunities that will help chiropractors further develop their competencies and skills in key areas.

Drug driving

In March 2015, new regulations came into force in England and Wales whereby it is an offence to drive with a specific controlled drug in the body above that drug’s accepted limit. Eight prescription drugs/drug groups, and eight illicit drugs, were added to the list at that time. Regulations on amphetamine came into force in April 2015.

The total of nine prescription drugs is as follows, some of which, such as diazepam and opioids, are commonly prescribed to patients with musculoskeletal conditions:

  • amphetamine, eg dexamphetamine or selegiline
  • clonazepam
  • diazepam
  • flunitrazepam
  • lorazepam
  • methadone
  • morphine or opiate and opioid-based drugs, eg codeine, tramadol or fentanyl
  • oxazepam
  • temazepam

Patients must speak to their doctor before driving whilst taking any of the above drugs. Individuals can drive after taking these drugs if they’ve been prescribed them and followed advice on how to take them by a healthcare professional, and they aren’t causing them to be unfit to drive, even if the level of the drug is above the specified limits.

Further information for healthcare professions is available here.

Managing Low Back & Radicular Pain

A recent RCC Research Bulletin highlighted the comparative effectiveness of spinal manipulation for sciatica. The findings outlined in the bulletin are compatible with the ‘Pathfinder’ Pathway of Care for Low Back and Radicular Pain (NHS England, 2014) which provides a generic pathway for the management of low back and radicular pain based on a consensus of all stakeholders.

The pathway identifies manual therapy (manipulation) and acupuncture as appropriate for radicular pain where there is pain and/or sensory deficit; however, emergency surgical referral is required for suspected spinal cord or cauda equina syndrome. Urgent referral for MRI or surgical opinion is also required for suspected tumour, infection or severe or progressive motor deficit (e.g. foot drop) and MRI is recommended if a patient fails to improve with conservative therapy.

New Rules of Consent

The BMJ has highlighted a recent UK Supreme Court ruling that effectively means a doctor can no longer decide what a patient needs to know about the risks of treatment when seeking consent. Doctors will now have to take reasonable care to ensure the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. Furthermore, what counts as material risk can no longer be based on a responsible body of medical opinion, but rather on the view of ‘a reasonable person in the patient’s position’. The BMJ article is available here. The RCC feels it is important for chiropractors to be aware of this development which is relevant to all healthcare professionals.

Pathfinder Project: Low Back and Radicular Pain

NHS England Pathfinder Projects were established to address high value care pathways which cross commissioning and health care boundaries. Many conditions require a pathway of care which moves from the GP through primary care and community services and into secondary care, and sometimes specialised services.

Difficulties in commissioning across boundaries can cause artificial interruptions in what should be a seamless care pathway and the Pathfinder Projects are designed for all stakeholders to work collaboratively to examine in depth these health care interfaces and to develop commissioning structures to commission care across the whole pathway.

The Trauma Programme of Care Board selected low back pain and radicular pain as their Pathfinder Project and the Clinical Group, which included RCC Health Policy Unit Chair, Mark Gurden FRCC, has now produced its report, available here.

Atrial Fibrillation Recommendations

Simple, manual palpation of your patient’s pulse could help in the detection of atrial fibrillation (AF), a condition that causes an irregular heart rate and is a significant risk factor for stroke, particularly in the elderly. A recent article in Pulse suggests that more opportunistic testing of patients could help in the detection of AF which is asymptomatic in an estimated 30-40% of people. Currently NICE recommends manual pulse palpation in any patient with one symptom such as breathlessness, palpitations, dizziness, chest discomfort or stroke/transient ischaemic attack.

Chiropractors need to be aware of these recommendations and be alert to the signs and symptoms of AF. For patients who are undiagnosed, this simple test could reveal the need for immediate referral to a GP.

Osteoarthritis: care and management in adults

The National Institute for Health and Care Excellence (NICE) has released an updated guideline on the management of osteoarthritis, entitled Osteoarthritis: care and management in adults (CG177). This guideline looks at the diagnosis and management of people with osteoarthritis and makes key recommendations that are relevant to the way that chiropractors manage their patients.

The guideline recommends that health professionals use an “holistic approach to osteoarthritis assessment and management” and that all patients with clinical osteoarthritis are offered the following core treatments:

  • Access to appropriate information
  • Activity and exercise
  • Interventions to achieve weight loss if the person is overweight.

The recommendations for exercise suggest local muscle strengthening and aerobic fitness irrespective of age, co-morbidity, pain severity or disability. Additionally, it is recommended that manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip.

The RCC’s Pain Faculty has commented here.