In 2011, the Province of Manitoba and Mount Carmel Clinic established a chiropractic clinic to assess, diagnose and treat musculoskeletal (MSK) injuries and conditions among the residents of Point Douglas in Winnipeg’s North End. For a variety of reasons, including low socioeconomic status, many of the residents typically face barriers to accessing healthcare. In accordance with Manitoba Health’s recognition of the importance of chiropractic care, the program covers up to 12 chiropractic visits per year for most Manitobans; however, patients referred to Mount Carmel’s clinic are never asked to pay out-of-pocket for services.
“We are very pleased chiropractic care is now being offered as part of the wide range of services at our clinic. This service is a healthy option and is offered to area residents, individuals on employment and income assistance and the working poor,” Mount Carmel Executive Director Betty Edel told Canadian Chiropractor Magazine in 2011.
Point Douglas is an inner-city neighbourhood with a multicultural population of mostly low socioeconomic status, which presents certain challenges to providing chiropractic care. People living in poverty often lack access to primary healthcare, and the realities of daily life can contribute to chronicity and disability. Chiropractors do have the expertise to successfully treat MSK injuries and conditions endemic to those living in such circumstances; however, the challenge lies in understanding the unique characteristics of the MSK and comorbid conditions affecting Mount Carmel’s chiropractic patients. Such an understanding helps to ensure better outcomes in often disaffected and transient populations.
Dr. Steven Passmore, DC, PhD, an Assistant Professor in the College of Rehabilitation Sciences, Faculty of Health Sciences at the University of Manitoba, specializes in developing and implementing performance-based outcome metrics designed to understand the impact of clinical chiropractic interventions on unique patient populations. He is the primary investigator examining the outcomes related to the integration of chiropractic services at Mount Carmel Clinic.
“The chiropractic clinic at Mount Carmel is an ideal environment for developing clinical understanding of complex conditions as well as identifying when they create a barrier to improvement,” he said. “Different populations respond to care differently.”
For two years, Dr. Passmore served as a Without Compensation (WOC) chiropractor in a US Veterans Affairs Medical Center in Buffalo, New York. This experience led to his interest in developing metrics to quantify the outcomes of chiropractic interventions on unique populations, and, as he said, provide insight into how they might respond to care differently.
His work with US veterans became the basis for a study on the outcomes of chiropractic treatment on veterans suffering from neck and low back pain.1 Dr. Passmore and his colleagues were able to identify those characteristics of comorbid conditions that were distinct to veterans, especially those with Post-Traumatic Stress Disorder (PTSD). Veterans diagnosed with PTSD, when asked to self-report pain outcome scores, reported significantly less improvement than those without PTSD.
“Patients with PTSD would continue to report no improvement on pain, even though it was obvious they had improvement on levels of disability,” he said. “By redefining how we score improvement – from the experience of pain to improvement in movement – we could effectively evaluate the outcome of chiropractic treatment.”
Similarly, Dr. Passmore has developed a database of key metrics derived from Mount Carmel chiropractic patients, such as comorbid conditions, service utilization, missed appointments and follow-up data in order to gain clinical understanding about treatment outcomes. This information will eventually prove invaluable in identifying barriers that impact prognosis, and provide information needed on how to individualize care to better meet the needs of patients.
Dr. Passmore has systematically collected demographic information and key outcomes that will help researchers and clinicians better understand the population treated, including complex patient presentations. Preliminary results suggest that an important proportion of patients may suffer from a wide array of comorbidities, including mental health disorders, addictions and chronic conditions. The management of complex patients requires an integrated approach to care.
Furthermore, Dr. Passmore aims to collect data to inform best practices for the management of MSK conditions, specifically those suffering from comorbidities. Particularly, Dr. Passmore is interested in outcomes related to dosage. For example, so far, the data reveals that 12.7 chiropractic visits are needed in an average course of care.
The Mount Carmel Clinic’s chiropractic program is unique for many reasons – a dedication to a holistic, interprofessional approach to healthcare, an emphasis on cultural sensitivity to its patients, and a commitment to addressing the roots of health problems in one disadvantaged community – but what stands out the most is the depth of the strategic study aimed to help make chiropractic care more effective and accessible to similar disenfranchised Canadians.
1. Dunn, A.S., Passmore, S.R., Burke, J., Chicoine, D. (2009). The relationship between posttraumatic stress disorder and clinical outcomes within a Veterans Affairs Medical Center chiropractic clinic. Military Medicine, 174, 578-83.