MSK disorders
To point out that MSK conditions are a massive health problem has become cliché, but it is nonetheless an indisputable fact [
19,
20]. What is more, MSK conditions are often poorly managed with therapies of questionable effect and with the potential for severe complications and side effects [
21‐
23]. We shall use LBP as the primary example:
Paracetamol and Non-Steroidal Anti-Inflammatory drugs have no convincing clinical effect on spinal pain over placebo [
24‐
26]. Whilst opioids do appear more effective than placebo, the effect size is not large; the numbers-needed-to-treat is three times that of the numbers-needed-to-harm, and opioid use is associated with severe complications and potential for abuse and should not generally be recommended in the management of LBP [
27,
28]. Corticosteroids are not commonly used and are associated with only slightly better outcomes in radicular LBP compared to placebo, and probably no better for other types of LBP [
29]. Orthopedic surgery in general (not spine) has been found to be comparable to placebo [
30] and, whilst there are no placebo controlled trials for spinal disk surgery, the effects compared to conservative treatment are not impressive or long lasting [
31,
32]. For spinal fusion surgery, there are also no placebo controlled trials, and effects are similar to conservative care [
33]. Several controlled trials do exist for vertebroplasty, which is found to be no better than placebo [
34], and, in general, surgery is found to have large contextual effects, especially on pain [
35]. For exercise therapy, the evidence demonstrates it to be safe but of limited effect size, and, furthermore, the specifics of the type of exercise seem not to matter– i.e., any exercise is better than none [
36,
37]. The same holds true for SMT [
38], which has only slightly better or similar effects on short, intermediate and long-term pain and function compared to other recommended treatments (e.g., exercise therapy) and non-recommended treatments (e.g., ultrasound and corsets). Further, there is no evidence that the type of SMT makes an important clinical difference.
Thus, although a veritable smorgasbord of treatments is available for patients with MSK disorders like LBP, and while some are more expensive or associated with higher risks, none has proven decisively superior to others. However, exercise and SMT stand out as being both safe and inexpensive.
Furthermore, the organization of healthcare services and the roles of healthcare providers matter. For instance, the catastrophic impact of the opioid crisis is well documented (see the Centers for Disease Control website for an overview [
39]), the coverage policies of third-party payers affects patient behaviours and are important for healthcare utilization and outcomes [
40,
41] and the risk of opioid use has been demonstrated to be lower with chiropractic care [
42,
43].
A new clinical role
In short, it is becoming increasingly clear that MSK conditions, such as LBP, will generally not be cured by drugs or surgery, as early chiropractors predicted. However, neither will they be cured by SMT, exercise, or other known conservative approaches. Instead, as such conditions are often recurring and fluctuating, they need to be managed and self-managed safely and rationally in the long-term. Each of the treatments currently available may have a role to play in that long-term management, but none of them, including SMT, have proven decisively superior to the others and clinicians therefor need a broad-focus armamentarium to choose from.
This suggests a need for
someone (a healthcare professional) rather than
something (a treatment) to play a pivotal role for long-term management. That
someone should assume a central and directing role in a collaborative interdisciplinary setup [
44]. We consider chiropractors well suited for such a role, at least in some countries and settings, and adapting chiropractic practice to the reality of MSK disorders, as it has been uncovered by growing scientific evidence, constitutes a window of opportunity for the profession.
Future roles for chiropractors
Chiropractors’ specialized pre-graduate training with particular emphasis on MSK disorders, a tradition for conservative clinical management together with close contact with their patients, often well-developed interpersonal skills such as clinical relationship building, and high availability already single them out as ideal clinical players in this area of healthcare. Nevertheless, it is a role which will require a particular emphasis on new and presently de-prioritized skills.
Near the top of the list of new priorities is the ability to work in collaboration with other professionals, based on extensive knowledge of all the clinical facets relevant to the long-term management of MSK disorders, a knowledge which presently is patchy. This includes appropriate use of the range of evidenced interventions and mediating contextual factors that are available, an ability to judge when it would be appropriate to secure timely referral for specialist evaluation (requiring relevant referral networks), an insight into how to support self-management and to avoid harmful illness behaviour, and knowledge and skills making it possible to support high levels of functioning and employment. In addition, familiarity with the complex workings of national healthcare systems, multidisciplinary healthcare settings, and networks will be necessary. All this would require additional training and certifications. In many ways, such a role is diametrically opposite to a primary care solo practice where the main focus of examination is to find it and the mainstay of treatment is to fix it with SMT, and the response to failure is to adapt the SMT technique and try again.
Against this background, technical eminence in the application of SMT will not suffice anymore if the profession’s aspirations are to talk to and work with anyone other than their patients. That is central to avoiding becoming increasingly isolated and marginalized from the wider healthcare landscape. In turn, it will require effective and coordinated collaboration with, not only other health-care professionals, but also employers, social workers, public authorities, third party payers, and other relevant stakeholders.
This imperative is more acute in some national jurisdictions than others. For example, osteopaths in the UK are already part of a governmentally recognized group of healthcare professions, the Allied Health Professions. This group enjoys integration with or opportunities for integration within the wider healthcare system along with career progression and skills development funded by government sources. Presently, chiropractors remain the only regulated profession in the UK absent from this group, with all the ensuing barriers to accessing resources, professional progression, and public recognition that the exclusion from such cultural legitimization might bring [
45].
It is clear that a central directing role, such as we have described it, will prove a very different role from the one most chiropractors assume today, and getting there will necessitate willingness to adapt and embrace new perspectives from an otherwise very conservative profession.
It will also define a new role for SMT within chiropractic: from an identity-defining paradigm to simply one of many tools in a much larger armamentarium within a comprehensive package of care. Further, it requires the acknowledgement that this wider armamentarium is not the sole responsibility of the chiropractor but that it is to be provided by a group of collaborating practitioners. Such a change is not given and far from trivial, albeit essential. As we see it, three paths now lie open for the future of the profession;
Path 1: Chiropractic could re-invent itself with some urgency, with less focus on the role of SMT and shift away from a chiropractic identity as providers of SMT within a distinct theoretical framework, towards a broader role as coordinators of long-term management of MSK disorders well-integrated in the wider health-care landscape [A role as an MSK manager].
Path 2: Chiropractic could give up any ambitions of better mainstream integration in the healthcare system/market and embrace an identity as unambiguously alternative on par with naturopathy, homeopathy, reflexology, etc. [A role as alternative fringe practitioners].
Path 3: Chiropractic could accept a limited albeit mainstream role as manual therapists on par with several other professions in a setting, where SMT is prescribed as a delegated task in the long-term management of MSK, directed and coordinated by someone else [A role as a manual therapist].
Either one of these alone represents a potential future path for the profession, but all three at the same time do not. Conversely, these paths are not equally realizable in all countries and cultural settings.