A systematic review and consensus update recently published in the journal Manipulative and Physiological Therapeutics has taken aim at an important topic for chiropractors as we deal with an increasingly aging population. Currently, 15% of chiropractic patients are over the age of 60 [1]. With the World Health Organisation advising us that the number of people in this age group will double by 2050, it’s a good time to reflect on what best practice is for this cohort [2].
The World Health Organisation’s report raises a good point, in that major societal changes will be required as our population ages. Among their recommendations is an astute observation that the health of these ‘older people’ will play a pivotal role in allowing them to continue functioning and participating in society [1].
This lead the WHO to assert that key part of healthy aging is to increase or maintain functional ability [1]. This puts chiropractic in an interesting position. The authors of the systemic review and consensus update, Hawk et al, cited a study which indicated “when the supply of DCs in a particular geographic region is greater, primary care medical visits decrease in the Medicare population in that region [1].” While this supported the idea that older adults may use chiropractic as the sole management for common musculoskeletal complaints, it also points to the chiropractor as being a vital, trusted part of the health-care team of these patients. Thus its important that we keep an eye out for the complexities that can arise in the age group.
The Process:
The systemic review took in articles that had been published since the original consensus project was reviewed, so the publication dates fell between October 1, 2009 and January 31, 2016. The literature search was built around the questions 1) “What is the effectiveness of chiropractic care, including spinal manipulation, for conditions experienced by older adults,” and 2) What are the adverse events associated with chiropractic care, including spinal manipulation, among older adults?” This lead to a pool of 199 articles, but following the application of exclusion criteria, just 6 articles about effectiveness or efficacy and 6 articles on safety were left standing.
These were then put before a DELPHI (research) panel of 37, with 6 experts being non-chiropractors.
The Findings:
Interestingly, no serious adverse events related to the intervention (spinal manipulation/ chiropractic care) were found in any of the studies. This challenged a perceived ‘causal relationship with spinal manipulation [1].” Among the articles examined were:
- A systemic review finding no causal link between chiropractic care and cervical artery dissection
- A case control study finding no significant association between chiropractic and the risk of vertebrobasilar artery stroke
- No epidemiological studies demonstrating an association between cervical manipulation and internal carotid artery dissection
Beyond looking at adverse effects though, the purpose of the review was to define the parameters of appropriate care for older adults.
Key findings from the review included:
- Awareness of the age-related changes and co-morbidities. The authors remarked, “The age-related changes in the neurologic and musculoskeletal systems of older adults create unique findings and presentations that may require specific consideration during the physical examination (such as peripheral neuropathy, age-related muscle loss, and loss of flexibility) [1].” It is an undeniable fact that older adults often present with more than one issue. This requires special management, even if that is as simple as communicating the risk of bruising because of blood thinning medication.
- An emphasis on evidence-based and patient-centred practice. The authors reinforced that the patient should be managed according to a combination of the best evidence available, the clinicians experience and expertise, and the patient’s preferences. At times, this could include cross-referrals to, or co-management with other clinicians. Also included in the recommendations is an emphasis on informed consent by the patient, or by a legal representative if there is an impairment issue. (Details are set out in the full report, reference below).
- Thorough case histories, and an eye for red flags. Although a thorough case history, with attention to stubborn or worsening symptoms should always be a factor, it was emphasized in this age group. Should a health red flag, indicative of an emergent life-threatening condition raise its head, there should be no hesitation on an appropriate cross-referral. A sensitive issue raised in the review was the psycho-social health of the patient. The authors advised that chiropractors be on the look-out for elder abuse, and aware of the social services and laws in their jurisdiction.
- Modification of manual procedures when treating older adults. This should always be done based on the history and physical examination of the patient, with special consideration for contraindications (osteoporosis, anti-coagulants, steroids etc). They flagged a scarcity of research in this area, and emphasised that the clinician must “rely on his or her clinical experience when determining the appropriate high-velocity low-amplitude manipulative procedure to use, in terms or patient positioning, to achieve the desired clinical effect [1].” Soft tissue work was flagged as potential addition to the management of such patients.
- A focus on care planning, disease prevention and health promotion. These areas spanned exercise, nutrition, social connectedness and living arrangements among other factors.
The full review is available online, and is well worth a read if you are among the thousands of chiropractors who work with older adults in your practice. It’s a great thing that we are living longer. But unfortunately for many, chronic pain, ailing health and declining cognitive skills mean they aren’t truly living. Chiropractic care is in a unique position to be able to help people regain and maintain optimal neurological function. What this study does is raise awareness for the fact that there are some distinct complexities that can raise their heads with this cohort. It pays to know what to look for and how best to support these precious patients.
References
[1] Hawk C, Schneider M, Haas M, Katz P, Dougherty P, Gleberzon B, Killinger L and Weeks J (2017), “Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update,” JMPT, DOI: http://dx.doi.org/10.1016/j.jmpt.2017.02.001
[2] Staff Writer (2015), “WHO: Number of people over 60 years set to double by 2050; major societal changes required,’ World Health Organisation, http://www.who.int/mediacentre/news/releases/2015/older-persons-day/en/ retrieved 3 April 2017
