Antonio P. Legorreta, MD, MPH; R. Douglas Metz, DC; Craig F. Nelson, DC, MS; Saurabh Ray, PhD; Helen Oster Chernicoff, MD, MSHS; Nicholas A. DiNubile, MD
Department of Health Services, UCLA School of Public Health, Los Angeles, Calif
BACKGROUND: Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations. This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal-specific consumption of health care resources within a large managed-care system.
METHODS: A 4-year retrospective claims data analysis comparing more than 700,000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit.
RESULTS: Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year, P<.001). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared with those without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399, P<.001).
CONCLUSIONS: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2)substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.
OBJECTIVE: To provide a qualitative systematic review of the risk of spinal manipulation in the treatment of lumbar disk herniations (LDH) and to estimate the risk of spinal manipulation causing a severe adverse reaction in a patient presenting with LDH.
DATA SOURCES: Relevant case reports, review articles, surveys, and investigations regarding treatment of lumbar disk herniations with spinal manipulation and adverse effects and associated risks were found with a search of the literature.
DATA SYNTHESIS: Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or cauda equina syndrome (CES) in patients presenting with LDH was calculated. This was compared with estimates of the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and surgery in the treatment of LDH.
RESULTS: An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million.
CONCLUSION: The apparent safety of spinal manipulation, especially when compared with other medically accepted treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.
Rheumatology and Rehabilitation Department, Mansoura Faculty of Medicine, Mansoura University
This new, single blinded placebo controlled study, conducted by the Mansoura Faculty of Medicine, conclusively demonstrates that maintenance care provides significant benefits for those with chronic low back pain.
Study Design: A prospective single blinded placebo controlled study was conducted.
Objective : To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic non-specific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low-back conditions after an initial phase of treatments.
Summary of background: SMT is a common treatment option for low back pain. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic non-specific LBP has not been studied.
Subjects and Methods: 60 patients with chronic, nonspecific LBP lasting at least 6 months were randomized to receive either: (1) 12 treatments of sham SMT over a one-month period, (2) 12 treatments, consisting of SMT over a one-month period, but no treatments for the subsequent nine months, or (3) 12 treatments over a one-month period, along with "maintenance spinal manipulation" every two weeks for the following nine months.
To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-month, 4-month, 7-month and 10-month intervals.
Results: Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029 respectively). However, only the third group that was given spinal manipulations during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the no maintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.
Conclusion SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.
Chiropractic Safe and Effective for Cervical Disc Herination
OBJECTIVE: This case study reports on three cases of patients with documented cervical disk herniations, who responded to chiropractic management and manipulative therapy.
CLINICAL FEATURES: Three patients complaining of neck pain with radiation of pain and tingling into the upper extremities had positive magnetic resonance imaging scans consistent with cervical disk herniations. They also had positive neurophysiologic testing with positive thermography scans and electrodiagnostic studies.
INTERVENTION AND OUTCOME: The patients were prescribed a treatment regimen consisting of chiropractic management including bracing, physiotherapy, cervical manipulative procedures, traction and exercises. The patients responded well to care as evidence by posttreatment MRI, electrodiagnostic studies, clinical exam findings and thermography scan findings.
CONCLUSION: Patients with and without nerve root compression secondary to cervical disk herniation can and do respond well to chiropractic care. Chiropractic management of this condition can and should be employed prior to more invasive treatment.
Chiropractic Reduces Health Care costs for Employers
Health Services Research, American Specialty Health, San Diego, CA 92101, USA. email@example.com
OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain.
DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit.
RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant.
CONCLUSIONS: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.
Chiropractic Reduces Workers Compensation Costs by Greater Than 50%
In 2002, the Texas Chiropractic Association (TCA) commissioned an independent study to determine the use and effectiveness of chiropractic with regard to workers' compensation, the results of which were published in February 2003. According to the report, chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries. They found: Lower back and neck injuries accounted for 38 percent of all claims costs. Chiropractors treated about 30 percent of workers with lower back injuries, but were responsible for only 17.5 percent of the medical costs and 9.1 percent of the total costs. These findings were even more intertesting: The average claim for a worker with a low-back injury was $15,884. However, if a worker received at least 75 percent of his or her care from a chiropractor, the total cost per claimant decreased by nearly one-fourth to $12,202. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent, to $7,632.
Last year, the Texas Chiropractic Association (TCA) commissioned an independent study to determine the use and effectiveness of chiropractic with regard to workers' compensation, the results of which were published in February. According to the report, Chiropractic Treatment of Workers' Compensation Claimants in the State of Texas, chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries, and is not a contributor to the state's rising worker's compensation costs.
The study considered two questions:
1. Does chiropractic play a significant role in driving the escalating costs in the Texas workers' compensation system?
2. Is chiropractic a cost-effective treatment option within the state's workers' compensation system?
To answer these questions, the national research/consulting firm MGT of America was hired to review more than 70 articles and published studies on the cost and effectiveness of chiropractic care. The firm also analyzed data on approximately 900,000 workers' compensation claims filed from 1996 to 2001.
Among the firm's findings:
Of the nearly 900,000 workers' compensation claims received from 1996 to 2001, only 14.6 percent of claimants were treated by doctors of chiropractic, and only 8.5 percent of those workers received more than half of their treatment from chiropractors.
Chiropractic care accounted for only 12.5 percent of medical fees and 6.9 percent of the total workers' compensation costs. However, the firm noted that these figures did not include the costs of pharmaceuticals, because insurers are not required to provide such information to the Texas Workers' Compensation Commission (TWCC). If those costs were included, the percentage of costs related to chiropractic care would have been even lower.
Lower back and neck injuries accounted for 38 percent of all claims costs. Chiropractors treated about 30 percent of workers with lower back injuries, but were responsible for only 17.5 percent of the medical costs and 9.1 percent of the total costs.
The average claim for a worker with a low-back injury was $15,884. However, if a worker received at least 75 percent of his or her care from a chiropractor, the total cost per claimant decreased by nearly one-fourth to $12,202. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent, to $7,632.
Based on its analysis, the firm reached two noteworthy conclusions:
1. Chiropractic's medical costs are the lowest in the state's workers' compensation system. "The existing body of research indicates that chiropractic is a cost-effective means of treatment for musculoskeletal injuries," the firm noted. "Chiropractic care is associated with lower medical costs and more rapid recovery in the overwhelming majority of studies concerning chiropractic care and workers' compensation costs." Data from the study also clearly linked increased use of chiropractic care with lower costs relative to lower back injuries.
The complete TCA/MGT study can be purchased from the TCA at: Texas Chiropractic Association, 815 Brazos, Suite 802, Austin, TX 78701 For more information, call (512) 477-9292.
Institute of Medical Biology (Biomechanics), Faculty of Health Science, University of Odense, Denmark
PURPOSE: To study whether the isolated intervention of high-speed, low-amplitude spinal manipulation in the cervical spine has any effect on cervicogenic headache.
DESIGN: Prospective randomized controlled trial with a blinded observer.
SETTING: Ambulatory outpatient facility in an independent research institution.
PARTICIPANTS: Fifty-three subjects suffering from frequent headaches who fulfilled the International Headache Society criteria for cervicogenic headache (excluding radiological criteria). These subjects were recruited from 450 headache sufferers who responded to newspaper advertisements.
INTERVENTION: After randomization, 28 of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The remaining 25 received low-level laser in the upper cervical region and deep friction massage (including trigger points) in the lower cervical/upper thoracic region, also twice a week for 3 wk.
MAIN OUTCOME MEASURES: The change from week 1 to week 5 in analgesic use per day, in headache intensity per episode and in number of headache hours per day, as registered in a headache diary.
RESULTS: The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group; this difference was statistically significant (p = .04, chi 2 for trend). The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group; this was significant at p = .03 (Mann-Whitney). Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant at p = .04 (Mann-Whitney).
CONCLUSION: Spinal manipulation has a significant positive effect in cases of cervicogenic headache.
The Backcenter, Ringe Hospital, Odense University Hospital, 5950 Ringe, Denmark, firstname.lastname@example.org
It is often claimed that up to 90% of low back pain (LBP) episodes resolve spontaneously within 1 month. However, the literature in this area is confusing due to considerable variations regarding the exact definitions of LBP as well as recovery. Therefore, the claim - attractive as it might be to some - may not reflect reality. In order to investigate the long-term course of incident and prevalent cases of LBP, a systematic and critical literature review was undertaken. A comprehensive search of the topic was carried out utilizing both Medline and EMBASE databases. The Cochrane Library and the Danish Article Base were also screened. Journal articles following the course of LBP without any known intervention were included, regardless of study type. However, the population had to be representative of the general patient population and a follow-up of at least 12 months was a requirement. Data were extracted independently by two reviewers using a standard check list. The included articles were also independently assessed for quality by the same two reviewers before they were studied in relation to the course of LBP using various definitions of recovery. Thirty-six articles were included. The results of the review showed that the reported proportion of patients who still experienced pain after 12 months was 62% on average (range 42-75%), the percentage of patients sick-listed 6 months after inclusion into the study was 16% (range 3-40%), the percentage who experienced relapses of pain was 60% (range 44-78%), and the percentage who had relapses of work absence was 33% (range 26-37%). The mean reported prevalence of LBP in cases with previous episodes was 56% (range 14-93%), which compared with 22% (range 7-39%) for those without a prior history of LBP. The risk of LBP was consistently about twice as high for those with a history of LBP. The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.
Ambrose Chiropractic Care 154 Pacific Highway Tuggerah Tel 0404 671 323