Bronfort G, Haas M, Evans R, Bouter L. “Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain: A Systematic Review and Best Evidence Synthesis.” Spine J. 2004 May-Jun;4(3):335-56. Review
The authors categorized 43 randomized controlled trials to assess the efficacy of Spinal Manipulative Therapy (SMT) for back and neck pain. They concluded that there are now more randomized controlled trials (46) studying the use of spinal manipulation for the management of low back pain than for any other treatment method. Overall, there was limited to moderate evidence (depending on the study) that spinal manipulative treatment of both chronic and acute lower back pain was more effective and provided more short-term relief than many other types of care, including prescription drugs, physical therapy and home exercise. There was moderate evidence that spinal mobilization was superior to physical therapy and some medical regimens for some types of neck pain. Their data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or mobilization as a viable option for the treatment of both low back pain and neck pain.
Descarreaux M, Blouin J, Drolet M, Papadimitriou S, Teasdale N. “Efficacy of Preventive Spinal Manipulation for Chronic Low Back Pain and Related Disabilities: A Preliminary Study.” Journal of Manipulative and Physiological Therapeutics 2004; 27: 509-14.
Non-specific back pain patients were treated with twelve chiropractic spinal manipulations over a one-month intensive period. The patients were then divided into two groups, one group acting as a control and another receiving maintenance spinal manipulation every three weeks for nine months. Both groups improved with chiropractic care and maintained that improvement during the tenth month study. The group receiving maintenance treatment every three weeks reported better disability scores after nine months than the control group. This study appears to confirm previous reports showing that low back pain and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and a reduction in the amount and intensity of pain episodes after an acute phase of treatment.
Fritz J, Whitman J, Flynn T, Wainner R, Childs J. “Factors Related to the Inability of Individuals With Low Back Pain to Improve With a Spinal Manipulation.” Physiological Therapeutics 2004; 84: 173-190.
The authors state that many interventions used by physical therapists for management of low back pain patients lack evidence supporting their effectiveness. Although spinal manipulation is one of the few interventions for low back pain supported by evidence, it appears to be underutilized by physical therapists. The purpose of this study was to determine factors might cause an inability to benefit from manipulation. The majority of the subjects (72 percent) receiving spinal manipulation showed improvement, consistent with previous clinical trials that have shown favorable results. The physical therapists that wrote this paper support the advice of clinical practice guidelines that advocate at least a trial of manipulation for all patients with a new onset of low back pain. This work was supported by a research grant from the Foundation for Physical Therapy.
Grunnesjo M, Bogefeldt J, et al. “A Randomized Controlled Clinical Trial of Stay-Active Care versus Manual Therapy in Addition to Stay-Active Care: Functional Variables and Pain.” Journal of Manipulative and Physiological Therapeutics 2004; 27: 431-41.
These medical researchers compared the effects of manual therapy, in addition to a stay-active concept, versus stay-active therapy only in low back pain patients. Manual therapy in low back pain has thus been found more effective than the referenced treatments in the majority of trials reviewed in preparation for this study. They found the manual therapy regime was more cost effective than the stay-active concept in acute and sub-acute low back pain patients. The manual therapy group had better pain reduction, less disability and more improvement in functional activities.
Hoiriis K, Pfleger B, McDuffie F, Cotsonis G, Elsangak O, Hinson R, Verzosa G. “A Randomized Clinical Trial Comparing Chiropractic Adjustments to Muscle Relaxants for Sub-Acute Low Back Pain.” Journal of Manipulative and Physiological Therapeutics 2004; 27: 388-98.
These researchers compared the relative efficacy of chiropractic adjustments with muscle relaxants and placebo/sham for sub-acute low back pain (two- to six-weeks duration). They found chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing the Global Impression of Severity Scale(GIS).
Bergman G, Winters J, Groenier K, Pool J, Meyboom-de Jong B, Postema K, Van Der Heijden G. “Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain.” Annals of Internal Medicine 2004; 141: 432-439.
These medical researchers from the Netherlands studied the effectiveness of manipulative therapy for the shoulder girdle in addition to usual medical care accelerated recovery of shoulder symptoms. More patients in the manipulative therapy group than those in the medical-only group reported full recovery or very large improvements. These favorable effects were maintained during the 52-week follow-up period. They recommend that general practitioners should consider referring patients with cervicothoracic dysfunction for manual therapy.
Aure O, Nilsen J, Vasseljen O. “Manual Therapy and Exercise Therapy in Patients with Chronic Low Back Pain.” Spine 2003; 28: 525-532.
Patients complaining of lower back or radicular pain were randomized to either manual therapy or exercise for a period of two months. Both groups of patients improved with treatment, however the manual therapy group shower significantly greater improvement on both short and long- (1 year) term follow-up. The physiotherapists from Norway who designed this study also observed a considerable reduction in sick leave for the manual therapy group.
Niemisto L, Lahtinen-Suopanki T, et al. “A Randomized Trial of Combined Manipulation, Stabilizing Exercises, and Physician Consultation Compared to Physician Consultations Alone for Chronic Low Back Pain.” Spine 2003; 28: 2185-2191.
These Finnish medical researchers randomly assigned 240 chronic low back pain patients to either manipulative treatment or a medical physician consultation. The manipulative group received four weeks of physician consultation, manipulation and exercise from an experienced manual therapist, while another group received only physician consultation and an educational booklet. Outcome was measured by pain intensity and back-specific disability. Both groups improved, however the patients treated with manipulation and exercise had more reduced pain and better self-rated disability than the consultation group alone.
Giles L, Muller R. “Chronic Spinal Pain - A Randomized Clinical Trial Comparing Medication, Acupuncture and Spinal Manipulation.” Spine 2003; 28: 1490-1503.
Australian patients with chronic lower back pain of at least 13 weeks duration were randomly assigned either to medication, needle acupuncture or spinal manipulation. The results provided evidence that in patients with chronic spinal pain, manipulation results in greater short-term improvement than acupuncture or medication. The patients receiving spinal manipulation also reported a much higher full recovery rate (27%) than either those receiving acupuncture (9%) or medication (5%).
Wolsko P, Eisenberg D, Davis R, Kessler R, Phillips R. “Patterns and Perceptions of Care for Treatment of Back and Neck Pain: Results of a National Survey.” Spine 2003; 28(3): 292-298.
These medical researchers conducted a national telephone survey of 2,055 adults, asking if they had back or neck problems during the past 12 months, and if yes, what type of treatment was received and how helpful was it. 33 percent of those surveyed reported having back or neck pain during the last year; 20 percent sought chiropractic care. Chiropractic providers were perceived as having been “very helpful “ for back or neck pain in 61 percent of the cases, in contrast to only 27 percent who perceived their medical care as being “very helpful.” When the patients who had pain in more than one area were surveyed, their preference for chiropractic was unquestionable. 72 percent of those treated by a chiropractor reported the treatment as “very helpful,” compared to only 19 percent of those who had seen conventional providers.
George B. McClelland, D.C., Testimony to the Department of Veterans Affairs' Chiropractic Advisory Committee; Foundation for Chiropractic Education and Research: March 25, 2003. http://www.chiro.org/LINKS/ABSTRACTS/Testimony_to_the_Department_of_Veterans_Affairs.html American Chiropractic Association report to the Veteran Administration; American Chiropractic Association: 1999. www.amerchiro.org/pdf/va_report.pdfHertzman-Miller R, Morgenstern H, Hurwitz E, et al. “Comparing the Satisfaction of Low Back Pain Patients Randomized to Receive Medical or Chiropractic Care: Results From the UCLA Low Back Pain Study.” American Journal of Public Health 2002; 92: 1628-1633.
Approximately one third as many back pain patients seek chiropractic care compared to those who seek medical care. The physician community is taking note of the chiropractors’ ability to treat lower back pain and their high patient satisfaction. In earlier randomized clinical trials, investigators found spinal manipulation to have similar or better rates of patient satisfaction when compared to medical approaches like physical therapy, McKenzie method and standard medical therapy. This study examined the differences in satisfaction between patients assigned to either medical care or chiropractic care in a managed care organization. In this randomized trial, the chiropractic patients were more satisfied with their back care after 4 weeks of treatment. One possible explanation is that the self-care advice and explanation of treatment had strong effects on patient satisfaction. They also point out that chiropractors might give more detailed physical examinations than do medical providers. They conclude that providers in managed care organizations might be able to increase the satisfaction of their low back pain patients by communicating advice and information to patients about their condition and treatment.
Hoving J, Koes B, De Vet H, Van Der Windt D, Assendelft W, Van Mameren H, Deville W, Pool J, Scholten R, Bouter L . “Manual Therapy, Physical Therapy or Continued Care by a General Practitioner for Patients with Neck Pain.” Annals of Internal Medicine 2002; 136: 713-7220.
In a randomized, controlled trial, researchers compared the effectiveness of manual therapy, physical therapy (PT) and continued care by a general practitioner (GP) in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) as for the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Additionally, patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. The magnitude of the differences between manual therapy and the other treatments (PT or GP) was most pronounced for perceived recovery. Because perceived recovery combines other outcomes, such as pain, disability and patient satisfaction, it may be the most responsive outcome measure.
Hawk C, Long CR, Boulanger KT. “Patient Satisfaction with the Chiropractic Clinical Encounter: Report from a Practice-Based Research Program.” Journal of the Neuromusculoskeletal System 2001; 9(4): 109-117.
When 2,987 patients from a variety of rural and urban locations in the United States and Canada completed a data collection survey, 85 percent stated, “Their chiropractor always listened carefully.” 85.3 percent stated, “The chiropractor explained things understandably.” 88.2 percent stated, “The chiropractor showed respect for what they had to say.” Overall, the majority of patients were highly satisfied with their care.
Gemmell HA, Hayes BM. “Patient Satisfaction with Chiropractic Physicians in an Independent Physicians Association.” Journal of Manipulative and Physiological Therapeutics 2001; 24(9): 556-559.
In this study, 150 chiropractic patients were surveyed. Chiropractic care received “excellent” remarks by percentage, in the following categories: Time to Get an Appointment – 84.9 percent; Convenience of Office - 57.7 percent; Access to Office by Phone - 77.3 percent; Length of Wait - 75.7 percent; Time Spent with Provider - 74.3 percent; Explanation of Treatment - 72.8 percent; Skill of Provider - 83.3 percent; Personal Manner of the Chiropractor - 92.4 percent. The “Overall Visit” category was given the “excellent” response by 83.3 percent of those surveyed.
Nyiendo J, Haas M, Goodwin P. “Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: a practice-based feasibility study.” Journal of Manipulative and Physiological Therapeutics 2000; 23: 239-45.
Patients with chronic (>6 weeks), recurrent lower back pain were treated by either a private chiropractor or a family medicine clinic. After one month of treatment, chiropractic patients averaged higher improvement across all outcome measurements. The differences between provider groups were most marked for the question involving satisfaction with overall care (chiropractic-90%; medical–52%). Chiropractic patients also reported greater improvement and in pain severity and functional disability. This study concluded that chiropractic patients expressed greater satisfaction regarding information and treatment provided.
Burton AK, Tillotson KM, Cleary J. “Single-blind randomized controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation.” European Spine Journal 2000; 9: 202-207.
Forty patients with confirmed sciatica were treated with either osteopathic manipulation treatment or chemonucleolysis. The pain endured by the patient was measured at 2 weeks, 6 weeks and one year. After a year patients from both groups were very similar in recovery. However, at 2 and 6 weeks those receiving manipulations reported greater improvement.
Giles L, Muller R. “Chronic Spinal Pain Syndrome: A Clinical Pilot Trial Comparing Acupuncture, a Non-Steroidal Anti-Inflammatory Drug and Spinal Manipulation.” Journal of Manipulative and Physiological Therapeutics 1999; 22: 376-81.
Patients referred to Townsville General Hospital outpatient Spinal Pain Unit in Australia for evaluation and treatment of chronic (>13 weeks) spinal pain were randomized to acupuncture, medication or spinal manipulation. After 30 days of treatment only the manipulation subgroup showed significant reduction in pain intensity. Remarkably, the manipulation group displayed uniform, significant, substantial improvements across all outcome measurements while in the two other intervention groups not a single significant improvement could be found.
Davis TP, Hulbert JR, Kassem KM, Meyer JJ. “Comparative Efficacy of Conservative Medical and Chiropractic Treatments for Carpal Tunnel Syndrome: A Randomized Clinical Trial” Journal of Manipulative and Physiological Therapeutics 1998; 21(5): 317-326.
This study sought to compare the effects of chiropractic care and conventional medical care for managing carpal tunnel syndrome. 91 patients with confirmed symptoms of carpal tunnel syndrome were divided into two groups. One group received decreasing amounts of ibuprofen over three weeks. The other group received manipulation of bony joints and soft tissues of the upper extremities and spine. The patients’ improvement was monitored through self-reports and analyses of the vibrometric sensibility of the hands. There was improvement in comfort, finger sensation and nerve conduction in both groups. For right hands affected by carpal tunnel the group who received medical care improved by 1.37 decibels according to the vibrometric tests. Those receiving chiropractic care improved by 3.05 decibels. Nilsson N, Christensen HW, Harvigsen J. “The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache.” Journal of Manipulative and Physiological Therapeutics 1997; 20(5): 326-330.
Of 53 individuals who were diagnosed with cervicogenic headaches, 28 individuals in the group received high-speed, low-amplitude spinal manipulation in the cervical spine two times a week for three weeks. The rest of the group received low-level laser to the upper cervical region and deep-friction massage in the lower cervical/upper thoracic region two times a week for three weeks. For those who received spinal manipulation treatment, the amount of headache hours per day decreased 69 percent; for those receiving laser treatment, the decrease was only 37 percent. Intensity of headache decreased 36 percent for those receiving manipulations and 17 percent for those receiving laser treatment. The use of pain relievers went down 36 percent for those receiving manipulations and was unchanged for those receiving laser treatment.
Meade TW, Dyer S, et al. “Randomized Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow Up.” British Medical Journal Aug 1995, Vol. 311.
741 patients were randomly allocated to either chiropractic or hospital outpatient management. A 1990 study by these researchers reported greater improvement in patients with low back pain treated by chiropractors. This paper looks at data after a three-year follow-up. According to total Oswestry scores, improvement in chiropractic patients was 29 percent more than those treated by hospitals. The beneficial effect of chiropractic on pain was particularly clear. Other scores (personal care, lifting, walking, standing, sex life, social life and traveling) also nearly all improved more in the patients treated with chiropractic care. The substantial benefit of chiropractic on intensity of pain is evident early on and then persists. A higher proportions of patients considered chiropractic care helpful in comparison with hospital treatments. The results show that chiropractic has a valuable part to play in the management of low back pain.
Boline PD, Kassem K, Bronfort G, Nelson C, Anderson A. “Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-Type Headaches: A Randomized Clinical Trial.” Journal of Manipulative and Physiological Therapeutics 1995; 18(3): 148-154.
This study compared the effects of spinal manipulation and pharmaceutical treatments for chronic tension headaches. Four weeks following the cessation of treatment, the pharmaceutical group demonstrated no improvement from the baseline. In the spinal manipulation group, headache intensity dropped 32 percent; frequency dropped 42 percent; and there was an overall improvement of 16 percent in functional health status.
Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. “The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project.” New England Journal of Medicine 1995; 333(14): 913-917.
This study sought to compare patients’ recovery and satisfaction for those with acute low back pain receiving care from the following six groups: Urban Primary Care Physicians; Rural Primary Care Physicians; Urban Doctors of Chiropractic (DCs); Rural DCs; Orthopedic Surgeons; and Primary Care Providers at a Group Model HMO. After six months, functional recoveries, return to work and complete back pain recoveries were similar for all groups. Satisfaction with care was highest for those visiting DCs.
Manga, Pran; Angus, Doug; Papadopoulos, Costa; Swan, William. "The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain." Richmond Hill, Ontario: Kenilworth Publishing, 1993.
A major study to assess the most appropriate use of available health care resources was reported in 1993 by the Ontario Ministry of Health. The report overwhelmingly supported the efficacy, safety, scientific validity and cost-effectiveness of chiropractic for low back pain. “There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic complications for low back pain patients. The literature suggests that chiropractic manipulation is safer than medical management of low back pain. There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost effective than medical management. The evidence includes studies showing lower chiropractic costs for the same diagnosis and episodic need for care. There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with physician management. Patient satisfaction is an important health outcome indicator and adds further weight to the clinical and health economic results favoring chiropractic management of low back pain.”
341 new and returning chiropractic patients in Minnesota and Wisconsin completed a patient satisfaction questionnaire. Overall, patients demonstrated a high level of satisfaction with their doctors of chiropractic. 84% of respondents felt their chiropractic care was “just about perfect.” 97% agreed or strongly agreed that they would “recommend this doctor to a friend or relative.”
Meade TW, Dyer S, Browne W, Townsend J, Frank AO. “Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment.” British Medical Journal 1990; 300(2): 1431-1437.
741 patients, who had neither been treated in the past month nor had contraindications to spinal manipulation, were treated either by doctors of chiropractic or with conventional hospital outpatient treatment for management of low back pain. Using the Oswestry scale, which quantifies pain, patients reported back on their improvement at six weeks, six months, one year and two years. At two years, chiropractic care resulted in a 7 percent benefit over hospital care.
Cherkin, D., MacCornack, F. “Chiropractic in the Mainstream: Patient Evaluations of Care from Family Physicians and Chiropractors.” Western Journal of Medicine March 1989.
This survey show that patients of chiropractors were three times as likely as patients of family physicians to respond that they were satisfied with the care they received for low back pain. Chiropractic patients were also more likely to have been satisfied with the amount of information they were given and to believe their doctors were concerned about them. This study was conducted at the Group Health Cooperative of Puget Sound, a 40-year-old staff-model Health Maintenance Organization (HMO) in western Washington State with 32,000 enrollees. The percentage of chiropractic patients who were “very satisfied” with the care they received for low back pain was triple that for patients of family physicians (66 percent versus 22 percent). Patients of family physicians were significantly less likely to report having received a graphic description of the causes of low back pain or instruction on exercise, posture and lifting techniques.
Compiled by Glenn Czulada DC Scranton, Pa. January 2005
Cost Effective Research
Sarnat, Richard; Winterstein, James. “Clinical and Cost Outcomes of an Integrative Medicine IPA.” Journal of Manipulative and Physiological Therapeutics 2004; 27: 336-347.
In 1999, a large Chicago HMO began to utilize Doctors of Chiropractic (DCs) in a primary care provider role. The DCs focused on assessment and evaluation of risk factors and practiced non-pharmaceutical/non-surgical prevention. Insurance claims and patient surveys were analyzed to compare clinical outcomes, costs and member satisfaction with a normative control group. During the 4-year study, this integrative medical approach, emphasizing a variety of Complimentary and Alternative Medical (CAM) therapies, realized lower patient costs and improved clinical outcomes for patients. The patients who used DCs as their primary care providers had 43 percent decreases in hospital admissions, 52 percent reductions in pharmaceutical costs and 43 percent less outpatient surgeries and procedures. Legorreta A, Metz D, Nelson C, Ray S, Chernicoff H, DiNubile N. “Comparative Analysis of Individuals With and Without Chiropractic Coverage.” Archives of Internal Medicine 2004; 164: 1985-1992.
A 4-year retrospective review of claims from 1.7 million health plan members analyzed the cost effects of having a chiropractic benefit in their HMO insurance plan. The data revealed that members with the chiropractic benefit had lower overall total annual health care costs. Back pain patients with chiropractic coverage also realized lower utilization of plain radiographs, low back surgery, hospitalizations and MRI’s. Back pain episode-related costs were also 25 percent lower for those with chiropractic coverage ($289 vs. $399).
Metz D, Nelson C, LaBrot T, Pelletier K. “Chiropractic Care: Is It Substitution Care or Add-on Care in Corporate Medical Plans?” Journal of Occupational and Environmental Medicine 2004; 46: 847-855.
In a 4-year study period, the claims of 8 million members insured by a managed health plan were evaluated to determine how patients utilize chiropractic treatment when they have a chiropractic benefit. They found that patients use chiropractic as a direct substitution for medical care, choosing chiropractic 34 percent of the time. Having a chiropractic benefit rider did not increase the number of patients seeking care for neuromusculoskeletal complaints.
UK BEAM Trial Team “United Kingdom Back Pain, Exercise and Manipulation Randomized Trial: Cost Effectiveness of Physical Treatments for Back Pain in Primary Care.” BMJ. 2004 Dec 11;329(7479):1381. Epub 2004 Nov 19
This study compared the benefits of spinal manipulation and exercise to “best care” in general practice for patients consulting for back pain. 1,287 patients were recruited, divided into treatment groups and followed for more than one year. Patients receiving manipulation and exercise had lower relative treatment costs and received more treatment benefits than those treated with general medical care. The authors believe that this study was able to show convincingly that manipulation alone and manipulation followed by exercise provided cost-effective additions to general practice.
Korthals-de Bos I, Hoving J, Van Tulder M, Van Molken R, Ader H, De Vet H, Koes B, Vondeling H, Bouter L. “Primary Care - Cost Effectiveness of Physiotherapy, Manual Therapy and General Practitioner Care for Neck pain: Economic Evaluation Alongside a Randomized Controlled Trial.” British Medical Journal 2003; 326: 911.
Patients who saw general practitioners for neck pain were randomly allocated to manual therapy (spinal mobilization), physiotherapy (mainly exercise) or general practitioner care (counseling, education and drugs). Throughout this 52-week study, patients rated their perceived recovery, intensity of pain and functional disability. Manual therapy proved to be the most effective treatment for neck pain. The clinical outcome measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. While achieving this superior outcome, the total costs of the manual therapy-treated patients were about one third of the costs of physiotherapy or general practitioner care.
Pelletier K, Astin J. “Integration and Reimbursement of Complementary and Alternative Medicine by Managed Care and Insurance Providers: 2000 Update and Cohort Analysis.” Alternative Therapies in Health and Medicine 2002; 8(1): 38-48.
Consumer demand for complementary and alternative medicine (CAM) is motivation for more managed care organizations (MCO’s) and insurance companies to assess the clinical and cost benefits of incorporating CAM. Providers identified “consumer demand” as the most critical factor underlying their decision to offer CAM coverage. Companies surveyed in the present study tended to rate “retaining existing enrollees” as being more important than in previous years. It is equally certain that there is a rapidly growing consumer demand for CAM. Market demand is one of the primary motivators for offering coverage of CAM, with consumer interest similarly cited as a key factor. Emphasis on what is validated by sound clinical and cost outcomes research rather than what is considered “alternative” versus “conventional” will be critical for reducing excessive medical utilization and containing rising medical care costs.
"Utilization, Cost, and Effects of Chiropractic Care on Medicare Program Costs." Muse and Associates. American Chiropractic Association 2001.
This study examines cost, utilization and effects of chiropractic services on Medicare costs. The study compared program payments and service utilization for Medicare beneficiaries who visited DCs and those who visited other types of physicians. The results indicated that chiropractic care could reduce Medicare costs. Medicare beneficiaries who had chiropractic care had an average Medicare payment of $4,426 for all Medicare services. Those who had other types of care had an average of $8,103 Medicare payment for all Medicare services. The per claim average payment was also lower with chiropractic patients, having an average of $133 per claim compared to $210 per claim for individuals who did not have chiropractic care.
Pran, Manga. “Economic Case for the Integration of Chiropractic Services into the Health Care System.” Journal of Manipulative and Physiological Therapeutics 2000; 23: 118-22.
This paper, written by Ontario Health Economist Pran Manga, PhD, makes the case that chiropractic is a safe, cost-effective treatment alternative. If further integrated into the health care system, he predicts reduced costs and improved outcomes. He points to the extensive body of literature which demonstrates that chiropractic is effective for neuromusculoskeletal disorders and the repeated evidence that patients often prefer chiropractic care over a medical approach. Evidence of effectiveness for medical care is not nearly as convincing for management of neuromusculoskeletal conditions.Branson, Richard. “Cost Comparison of Chiropractic and Medical Treatment of Common Musculoskeletal Disorders: A Review of the Literature after 1980.” Topics in Clinical Chiropractic 1999; 6(2): 57-68.
A cost comparisons study between DC-provided care and care provided by general and specialist MDs for individuals with musculoskeletal conditions found that the majority of retrospective studies had positive results for chiropractic care.
Manga, Pran. "Enhanced chiropractic coverage under OHIP (Ontario Health Insurance Plan) as a means for reducing health care costs, attaining better health outcomes and achieving equitable access to health services." Report to the Ontario Ministry of Health, 1998.
This study demonstrates the ways in which individuals in Ontario are deterred from the use of chiropractic care because it is not covered under OHIP. Greater chiropractic coverage under OHIP would result in a greater number of individuals visiting chiropractors and going more often. The study shows that despite increased visits to DCs, this would result in net savings in both direct and indirect costs. It is very costly to manage neuromusculoskeletal disorders using traditional medicine. If individuals were able to visit chiropractors under OHIP a great amount of money would be saved by the government. Direct savings for Ontario's healthcare system could be as much as $770 million and at the very least $380 million.
Smith, M; Stano, M. "Costs and Recurrences of Chiropractic and Medical Episodes of Low Back Care." Journal of Manipulative and Physiological Therapeutics 1997; 20(1): 5-12.
This study compared the health insurance payments and patient utilization patterns of individuals suffering from recurring low back pain visiting doctors of chiropractic to those visiting medical doctors. Insurance payments were higher for medically initiated episodes. Those who visited chiropractors paid a lower cost and were also more satisfied with the care given. Because of this, the study suggests that chiropractic care should be given careful attention by employers when using gate-keeper strategies.
Stano M, Smith M “Chiropractic and Medical Costs of Low Back Care.” Medical Care 1996; 34(3): 191-204.
This study compares health insurance payments and patient utilization patterns for episodes of care for common lumbar and low back conditions treated by chiropractic and medical providers. Using 2 years of insurance claims data, this study examines 6,183 patients who had episodes with medical or chiropractic first-contact providers. Multiple regression analysis, to control for differences in patient, clinical, and insurance characteristics, indicates that total insurance payments were substantially greater for episodes with a medical first-contact provider. The mean total payment when DCs were the first providers was $518, whereas the mean payment for cases in which an MD was the first provider was $1,020. Stano, Miron. "The Economic Role of Chiropractic Further Analysis of Relative Insurance Costs for Low Back Care." Journal of the Neuromusculoskeletal System 1995; 3(3): 139-144.
This retrospective study of 7077 patients compared costs of care for treatment of common low back conditions when a chiropractor was the first provider versus when an MD was the first provider. Total payments for inpatient procedures were higher for MD initiated treatment and especially episodes that lasted longer than a single day. Outpatient payments were much higher for MD initiated treatments as well. Payments were nearly twice as great for the medically initiated cases and their outpatient payments were nearly 50% higher. Their statistical estimates indicate that the costs of care for common low back disorders using a chiropractor as first-contact provider are substantially lower than episodes in which a medical physician is the first- contact provider. The author concluded that “when our results are considered together with the recognition by the Agency for Health Care Policy and Research of the clinical efficacy of chiropractic for low back problems, it is clear that chiropractic deserves careful consideration in the strategies adopted by employers and third-party payers to control health care spending”.
Stano, Miron. "A Comparison of Health Care Costs for Chiropractic and Medical patients." Journal of Manipulative and Physiological Therapeutics 1993; 16(5): 291-299.
Comparison of cost for patients who received chiropractic care for neuromusculoskeletal problems to those who received medical and osteopathic care. One quarter of patients analyzed were treated by chiropractors. These patients had lower health care costs. "Total cost differences on the order of $1000 over the two year period were found in the total sample of patients as well as in sub-samples of patients with specific disorders." Lower costs are attributed to lower inpatient utilization.
Manga, Pran; Angus, Doug; Papadopoulos, Costa; Swan, William. "The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain." Richmond Hill, Ontario: Kenilworth Publishing, 1993.
This study reveals that if management of low back pain was shifted to chiropractors there could be a potential savings of millions of dollars every year. The study also revealed that spinal manipulation is both safe and more effective than drugs, bed rest, analgesics, and general practice medical care for managing low back pain.
Dean, David; Schmidt, Robert. "A comparison of the cost of chiropractors versus Alternative Medical Practitioners." Richmond, VA: Virginia Chiropractic Association, 1992.
This study is an assessment of the difference in cost of treatment between chiropractors and other practitioners in dealing with individuals who have similar back-related problems. This study analyzed individuals who had medical visits in 1980 and had a combination of eleven health problems including arthritis, disc disorders, bursitis, low back pain, spinal related sprains, strains and dislocations. Chiropractic care had a lower cost option for many back ailments.
....................................................State Specific Workers Compensation Studies
“Chiropractic Treatment of Workers’ Compensation Claimants in the State of Texas.” Executive Summary. MGT of America Feb 2003.
This retrospective study of workers’ compensation claims from 1996 to 2001 was conducted to determine the use and efficacy of chiropractic care in Texas. The researchers reviewed 900,000 claims during that time period to determine if chiropractic was cost-effective compared to medical treatment. They found that chiropractor treatment costs were the lowest of all providers. Their data clearly demonstrated that increased utilization of chiropractic care would lead to declining costs relative to lower back injuries.
Folsom BL, Holloway RW “Chiropractic care of Florida workers' compensation claimants: Access, costs, and administrative outcome trends from 1994 to 1999.” Topics in Clinical Chiropractic 2002; 9(4): 33-53.
This retrospective study of Florida workers’ compensation claims from 1994-1999 found that the average total cost for low-back cases treated medically was $16,998 while chiropractic care was only $7,309. Patients treated primarily by chiropractors were found to reach maximum medical improvement almost 28 days sooner that if treated medically. Findings from this analysis of the Florida Claims and medical files indicate that considerable cost savings and more efficient claims resolution may be possible with greater involvement of chiropractic treatment in specific low back cases and other specific musculoskeletal cases.
Jarvis KB, Phillips RB, Danielson C. “Managed Care Pre-approval and its Effect on the Cost of Utah Worker Compensation Claims.” Journal of Manipulative and Physiological Therapeutics 1997; 20(6): 372-376.
5000 claims from 1986 and 5000 from 1989 were examined for injured individuals in the Utah Worker Compensation Fund. The study compared cost for those who received chiropractic care and those who received medical care. From 1986 to 1989 the cost of care for chiropractic increased 12% while medical care increased 71%. The replacement of wages increased 21% for those receiving chiropractic care and 114% for those receiving medical care.
Tuchin PJ, Bonello R. “Preliminary Findings of Analysis of Chiropractic Utilization in the Workers' Compensation System of New South Wales, Australia.” Journal of Manipulative and Physiological Therapeutics 1995; 18(8): 503-511.
In this study researchers analyzed WorkCover Authority data from New South Wales. Of 1289 cases reviewed 30% had back problems. 12% employed chiropractic care for spinal injury workers’ compensation claims. The total payments for all cases using chiropractic and physiotherapy care were $25.2 million, which was 2.4% of the total payments. When 20 claims were chosen at random the average chiropractic cost of care was $299.65, while the average medical cost was $647.20. A trend in data collected indicated that when greater than 60% of total cost of treatment came from chiropractic care the number of days missed from work was 9.5. When less than 60% of total cost of treatment came from chiropractic care the number of days missed from work was 50.3.
Ebrall PS. “Mechanical Low Back Pain: A Comparison of Medical and Chiropractic Management within the Victorian Workcare Scheme.” Chiropractic Journal of Australia 1992; 22(2): 47-53.
This study reviewed claims made in a twelve-month period involving work related mechanical low-back pain. Management by chiropractic care and medical care were compared. 39% of claims reviewed for individuals visiting chiropractors required compensation days while 78% of claims for those visiting medical doctors required compensation days. The average number of compensation days needed for those visiting chiropractors was 6.26 days and 25.56 days for those visiting medical practitioners.
Jarvis KB, Phillips RB, Morris EK “Cost Per Case Comparison of Back Injury Claims of Chiropractic Versus Medical Management for Conditions With Identical Diagnostic Codes” Journal of Occupational Medicine 1991; 33(8): 847-852.
This workers’ compensation study conducted in Utah compared the cost of chiropractic care to the costs of medical care for conditions with identical diagnostic codes. The study indicated that costs were significantly higher for medical claims than for chiropractic claims. The sample consisted of 3062 claims or 40.6% of the 7551 estimated back injury claims from the 1986 Workers' Compensation Fund of Utah. For the total data set, cost for care was significantly more for medical claims, and compensation costs were 10-fold less for chiropractic claims.
Nyiendo, Joanne. “Disabling Low Back Oregon Workers' Compensation Claims. Part II: Time Loss.” Journal of Manipulative and Physiological Therapeutics 1991; 14(4): 231-239.
This report focused on time lost for individuals who visited DCs versus those who visited MDs for treatment of low back pain. Median missed days of work for individuals with similar severity of injury was 9.0 days for those visiting DCs and 11.5 for individuals visiting MDs. Individuals visiting chiropractors more often returned to work having missed one week or less of work days. There was no difference in time lost for individuals visiting DCs and MDs with no previous history of low back pain. For claimants with a history of chronic low back problems, the median time loss days for MD cases was 34.5 days, compared to 9 days for DC cases. It is suggested that chiropractors are better able to manage injured workers with a history of chronic low back problems and to return them more quickly to productive employment.
Nyiendo, Joanne, Lamm, Lester. "Disabling Low Back Oregon Workers' Compensation Claims. Part I: Methodology and Clinical Categorization of Chiropractic and Medical Cases." Journal of Manipulative and Physiological Therapeutics 1991; 14(3): 177-184.
This study examined 201 randomly selected workers' compensation cases that involved low back injuries that were disabling. The study found individuals who visited DCs less often initially had more trips to the hospital for their injuries than those visiting MDs.
Johnson MR, Schultz MK, Ferguson AC. "A Comparison of Chiropractic, Medical and Osteopathic Care for Work-Related Sprains/Strains." Journal of Manipulative and Physiological Therapeutics 1989; 12(5): 335-344.
This study analyzed data on Iowa state record from individuals in Iowa who filed claims for back or neck injuries in 1984. The study compared benefits and the cost of care received by individuals from MDs, DCs and DOs. There was a focus on individuals who missed days of work and were compensated because of their injuries. Individuals who visited DCs missed on average at least 2.3 days less than individuals who visited MDs and 3.8 days less than individuals who saw DOs. Less money was dispersed as employment compensation on average for individuals who visited DCs. On average, the disability compensation paid to workers for those who visited DCs was $263.66, $617.85 for those who visited MDs, and was $1565.05 for those who visited DOs.
Wolk, Steve. "An Analysis of Florida Workers' Compensation Medical Claims for Back-Related Injuries." Journal of the American Chiropractic Association 1988; 27(7): 50-59.
This study is an analysis of worker's compensation claims in Florida from June through December of 1987. All of the claims analyzed were related to back injuries. The greater purpose of this study was to compare the cost of osteopathic, medical and chiropractic doctors. The cost of drugs was not included in the analysis. The results of the study lead to the finding that individuals who had compensable injuries and were treated by chiropractors often times were not forced to be hospitalized. It also revealed that chiropractic care is a "relatively cost-effective approach to the management of work-related injuries."
Compiled by Glenn Czulada DC Scranton, Pa. January 2005