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Chiropractic Research-Chronic
Pain
A compilation of research Related
Primarily to Chronic pain and
spinal manipulation
Submitted by: Ronald J. Farabaugh, D.C.
The Problem…
Generally, although the profession, the public, and other
health professionals need guidance, as a rule we have few
problems with treatment associated with acute pain or acute
episodes of chronic pain. Acute pain patients are usually
treated and released with a minimal of controversy. The
majority of patients suffering chronic pain are treated
effectively in episodes/bursts of care.
However a subset of chronic pain sufferers exist who require
ongoing “supportive care”, i.e., schedule ongoing care, often
at 1-2 visits per month. This is the same population of
patients ingesting large amounts of drugs and often
managed, or miss-managed, in pain management centers
across the nation.
A Message to the Profession concerning
literature related to chronic pain.
Obviously limited quality literature exists related to the issue
of supportive care dosage, etc. At the same time enough
research has been published of mixed quality to rationally
justify the use of spinal manipulation, in addition to other
types of intervention, for chronic pain sufferers.
No singular treatment intervention has superior footing in
terms of research related to chronic pain management. In
today’s society chronic pain management is a team sport,
and chiropractic should assume its rightful place on the
“team”.
Available Topics….
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Chronic pain
Cost Studies
Drug Issues
Diagnostic Test Accuracy
Etiology of Pain
Whiplash
Soft tissue healing
Recurrent nature of pain
Pain vs. Function
Spinal Manipulation
The Neurological Basis for Chronic Pain
Two important studies…
Spine 2004; 29(2):182-188 Characterization of Acute
Whiplash-Associated Disorders. Sterling, PhD, et al.
Conclusions.
Acute whiplash subjects with higher levels of pain and disability
were distinguished by sensory hypersensitivity to a variety of
stimuli, suggestive of central nervous system sensitization
occurring soon after injury.
These responses occurred independently of psychological distress.
These findings may be important for the differential diagnosis of
acute whiplash injury and could be one reason why those with
higher initial pain and disability demonstrate a poorer outcome.
Evidence for spinal cord hypersensitivity in chronic pain
after whiplash injury and in fibromyalgia. Banic B, et al.
Pain; 2004 Jan;107(1-2) p7 - 15
Patients with chronic pain after whiplash injury and fibromyalgia
patients display exaggerated pain after sensory stimulation.
Because evident tissue damage is usually lacking, this
exaggerated pain perception could be explained by
hyperexcitability of the central nervous system.
We provide evidence for spinal cord hyperexcitability in patients
with chronic pain after whiplash injury and in fibromyalgia
patients. This can cause exaggerated pain following low
intensity nociceptive or innocuous peripheral stimulation. Spinal
hypersensitivity may explain, at least in part, pain in the
absence of detectable tissue damage.
Maintenance and Supportive
Care Studies
“Maintenance Care: Health Promotion Services
Administered to US Chiropractic Patients Aged 65 and
Older, Part II”, Rupert, Manello, Sandefur, JMPT, Vol 23, No. 1,
January 2000, pp. 10-19.
·
Objective: Obtain information regarding multiple health issues of
patients age 65 and over who have had a long-term regimen of
chiropractic health promotion and preventive care.
Design: 65 years +, “health promotion and prevention services”
for at least 5 years @ min. of 4/yr, used SF-36D survey, 73 DCs,
tx not just CMT, stretching exercise (68.2%), aerobics (55.6%),
dietary advice (45.3%), and a host of other prevention
strategies, including vitamins and relaxation.
o
16.95 visits to DC/yr vs. 4.76 visits/yr to MD.
Maintenance Care (Rupert study), cont’d.
Results:
DC avg. only $3,106 which is 31% lower of the national average healthcare costs
for the same age group.
DC avg is lower than the national avg. for US citizens
Of all ages, which was $3,510.
Pts. Receiving maintenance DC spent an avg. of $1,723 for hospitalizations.
The per capita expenditures for Medicare hospitalization was $5,121 or 51% of
the total cost of health care services.
Maintenance Care (Rupert study), cont’d.
Conclusions:
• DC visits 2x vs. MDs, but 50% reduction in # of MD visits.
•Therefore, DC treatment “replaces”, not compliments, MD care.
• Extreme differences in Hospitalization costs.
• “Total annual cost of health care services for the patient
receiving MC was conservatively 1/3 of the expense made
by US citizens of the same age.”
Chiropractic Patients in a Comprehensive Home-Based Geriatric Assessment, Followup and Health Promotion Program, Coulter, Hurwitz, Aronow, Cassata, Beck, Top Clin Chiro
1996; 3(2):46-55, 1996
Purpose: To assess characteristics of older patients who seek chiropractic care.
Methodology: A detailed examination of a database collected during a randomized clinical trial
testing the effectiveness of a comprehensive geriatric assessement program was performed. 3 year
randomized trial, 75 years of age and older.
Results: Sample size of 414, with 23 receiving chiropractic care. DC users were:
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Less likely to have been hospitalized
Less likely to have used a nursing home
More likely to report a better health status,
More likely to exercise vigorously
More likely to be mobile in the community
Less likely to use prescription drugs
Conclusion: Results suggest a need to develop chiropractic models that address the
special preventive and rehabilitative needs of the older patient.
Chiropractic maintenance care and quality of life of a
patient presenting with chronic low back pain. Wenban AB,
Nielsen MK. J Manipulative Physiol Ther. 2005 Feb;28(2):136-42.
Objective To report on a 26-year-old female patient presenting with uncomplicated chronic low
back pain who received chiropractic maintenance care using 2 quality of life outcome assessment
instruments. Outcome measures Short-form (SF-36) subscales, Quality of Well-Being Scale,
Visual Analog Scale, and number of tender vetebral spinous processes.
Conclusion The patient appeared to experience improvement in quality of life while showing
signs suggestive of improved spinal function. The relationship between indicators of vertebral
subluxation and quality of life deserves further investigation using a research design that allows
for exploration of possible causal relationships.
Efficacy of preventive spinal manipulation for chronic low-back pain and
related disabilities: a preliminary study. Descarreaux M, Blouin JS, Drolet M,
Papadimitriou S, Teasdale N. J Manipulative Physiol Ther. 2004 Oct;27(8):509-14.
Related Articles, Links
OBJECTIVE: To document the potential role of maintenance chiropractic spinal manipulation to
reduce overall pain and disability levels associated with chronic low-back conditions after an
initial phase of intensive chiropractic treatments.
METHOD: 2 groups; (1) 12 tx in 1 mo., no tx for 9 mo.
(2) 12 tx in 1 mo., 1 tx every 3 weks for 9 mo.
RESULTS: Both groups maintained their pain scores at levels similar to the postintensive
treatments throughout the follow-up period. For the disability scores, however, only the group
that was given spinal manipulations during the follow-up period maintained their postintensive
treatment scores. The disability scores of the other group went back to their pretreatment levels.
CONCLUSIONS: Intensive spinal manipulation is effective for the treatment of chronic low
back pain. This experiment suggests that maintenance spinal manipulations after intensive
manipulative care may be beneficial to patients to maintain subjective postintensive treatment
disability levels.
Spinal Manipulation Literature
Related to Chronic pain
Woodward, Cook, et al. (1996). “Chiropractic Treatment
of Chronic Whiplash.” Injury 27 (9): 643-5
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“The accumulated literature suggests that 43% of patients will
suffer long-term symptoms following ‘whiplash’ injury. If
patients are still symptomatic after 3 months then there is
almost a 90% chance that they will remain so. No conventional
treatment has proven to be effective in these established
chronic cases.”
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“The results of this retrospective study would suggest that
benefits can occur in over 90% of patients undergoing
chiropractic treatment for chronic ‘whiplash’ injury.”
Following the chiropractic treatment, 93% of the patients
had improved.
A Symptomatic Classification of Whiplash Injury and the Implications for
Treatment. Khan, Cook, Gargan, and Bannister, University Department of
Orthopaedic Surgery, Bristol, UK. The Journal of Orthopaedic Medicine
21[1]1999.
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Objective: To determine which patients with chronic whiplash will
benefit from chiropractic treatment.
93 patients, 68 female.
Conclusion: Whiplash injuries are common. Chiropractic is the only
proven effective treatment in chronic cases. Our study enables
patients to be classified at initial assessment in order to target those
patients who will benefit from such treatment.
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57% make full recovery.
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Resolution of symptoms will have occurred within 2 years of injury.
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8% will remain disabled by their symptoms.
Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic
Surgery, Bristol, UK. The Journal of Orthopaedic Medicine 21[1]1999.
(cont’d)
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Non-responders do exist. Defining characteristics include: full range of
motion in association with neck pain, bizarre symptoms, female sex
and ongoing litigation.
McNab, found that symptoms persist in 45% of patients two years after
settlement of litigation.
Watkinson et al, found significantly higher frequency of degenerative
changes on radiological examination of patients who have sustained
soft tissue injuries than in a controlled population, place more
emphasis on the organic basis of symptoms.
Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic
Surgery, Bristol, UK. The Journal of Orthopaedic Medicine 21[1]1999.
(cont’d)
Whilst other studies have suggested that neurological signs (Group 2)
have a poorer prognosis, this was not the case amongst our patients.
Indeed, such patients showed the greatest improvement in disability
grade.
Group 1:
Neck pain, restricted ROM, no
neurological deficit.
Group 2:
Neurological symptoms, neck pain,
restricted motion.
Group 3:
Severe neck pain, full ROM, no
neurological symptoms.
Results: Organic pain causes psychological stress, not the result of it!
CHIROPRACTIC MORE EFFECTIVE THAN MEDICAL CARE FOR LBP;
JMPT – March 2004;27:160-9.
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Investigators pooled data on 60 chiropractic patients from 51 chiropractic clinics
and 11 patients cared for by general practitioners from 14 medical clinics. All
subjects had acute or chronic LBP.
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Findings showed that chiropractic care had significant advantages over medical
care. Specifically, “a clinically important advantage for chiropractic patients was
seen in chronic patients in the short-term (>10 [visual analog scale] points),
and both acute and chronic chiropractic patients experienced somewhat greater
relief up to 1 year.” Patients with leg pain below the knee appeared to have the
greatest advantage from chiropractic care.
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“Study findings were consistent with systematic reviews of the efficacy of spinal
manipulation for pain and disability in acute and chronic LBP,” write the study’s
authors. “Patient choice and interdisciplinary referral should be prime
considerations by physicians, policymakers and third-party payers in identifying
health services for patients with LBP.”
Meade Study: BMJ 1990
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A British ten year study concluded that
chiropractic treatment was significantly
more effective, particularly with patients
with chronic and severe pain
Bronfort, DC et al. JMPT 1996
“For the management of chronic back
pain, trunk exercise in combination with
manipulation or NSAIDs seems
beneficial and worthwhile.”
Giles LG, Muller R. JMPT 1999
Study compared spinal manipulation, needle
acupuncture, and NSAIDs for the treatment of
chronic back pain.
After 30 days, spinal manipulation was the only
intervention to achieve statistically significant
improvement.
Intervention by way of acupuncture or NSAIDs did
not result in significant improvements in any of the
outcome measures.
Manual Medicine 1986
CMT is both subjectively and objectively,
more effective at relieving low back pain than
a manual placebo treatment.
SPINE 1997 Maurits W. van Tulder, et al
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“…strong evidence for the effectiveness of
manipulation, back schools, and exercise therapy
for chronic low back pain, especially for short term
results.”
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Additionally, the study found that no single
therapeutic intervention was demonstrated to be
effective in the treatment of chronic LBP.
SPINE 1995 Triano, McGregor, et al
“There appears to be clinical value to
treatment according to a defined plan using
manipulation even in low back pain exceeding
7 weeks’ duration”
Chronic Spinal Pain: A Randomized Clinical Trial Comparing
Medication, Acupuncture, and Spinal Manipulation. Spine July 15,
2003; 28(14):1490-1502
Design: RCT, 115 patients, public hospitals multidisciplinary spinal pain
unit. Evaluated at 2, 5, and 9 weeks. Manipulation performed by DCs
with 18 adjustments or less. Drugs used; Celebrex, Vioxx,
paracetamol. Average duration of spine pain was 8.3 years for the
manipulation group.
Results: The highest proportion of early (asymptomatic status) recovery
was found for manipulation (27.3%), followed by acupuncture (9.4%)
and medication (5%).
Conclusions: The consistency of the results provides evidence that
in patients with chronic spinal pain, manipulation, if not
contraindicated, results in greater short-term improvement
than acupuncture or medication.
Bronfort. DC et al. JMPT 1996; 19(9): 570-582
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This was a randomized controlled study with a one
year follow-up in 174 chronic low back pain patients
(age 20-60) that compared the efficacy of five weeks
of: (1) spinal manipulation (SM) with trunk
strengthening exercises (TSE); (2) SM combined with
trunk stretching exercises; and (3) NSAIDs with TSE
all followed by 6 weeks of supervised exercise alone.
Bronfort. DC et al. JMPT 1996; 19(9): 570-582
(cont’d)
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Results: Outcomes at 5 and 11 weeks revealed no significant
group differences. Continuance of exercise during the followup year, regardless of the type of treatment, was associated
with a better outcome.
Conclusion: All three treatment regimens were associated with
similar and clinically important improvement over time and the
treatment was considered superior to the expected natural
history of long-standing chronic low back pain.
For the
management of chronic low back pain, trunk exercise in
combination with spinal manipulation or NSAIDs seems
beneficial and worthwhile.
Dabbs, D.C. and Lauretti, D.C., A Risk Assesment of Cervical
Manipulation vs. NSAIDs for the Treatment of Neck Pain. Journal
of Manipulative and Physiological Therapeutics. Vol. 18, number 8
Oct. 1995; 18:530-6.
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“The best evidence indicates that cervical manipulation for neck
pain is much safer than the use of NSAIDs, by as much as a
factor of several hundred times. There is no evidence that
indicates NSAID use is any more effective than cervical
manipulation for neck pain.”
Death rate for NSAID-associated GI problems at 0.04% per yr
amoung OA patients receiving NSAIDs, or 3,200 deaths in the
US per year.
He (Brandt) also noted that there are several animal studies and
human clinical studies that have actually implicated NSAIDs in
the acceleration of joint destruction.
Hoving et al. A Randomized Controlled Trial of Manual Therapy. Ann Intern Med.
2002;136:713-722. Manual Therapy, Physical Therapy, or Continue Care by a
General Practitioner for Patients with Neck Pain, A Randomized, Controlled Trial.,
Pages 713-722
Intervention: 6 weeks of manual therapy (specific mobilization
techniques) once per week, physical therapy (exercise therapy)
twice per week, or continued care by a general practitioner
(analgesics, counseling, and education).
“Conclusion: In daily practice, manual therapy is a favorable
treatment option for patients with neck pain compared with
physical therapy or continued care by a general practitioner.”
Osteopathic Manipulation No Better Than Sham Therapy for
Chronic Back Pain. Spine: July 8, 2003.
July 8, 2003 — Osteopathic manipulation is no better
than sham therapy for chronic nonspecific low back
pain, according to the results of a randomized trial
published in the July issue of Spine.
However, both osteopathic and sham manipulation
were more effective than no therapy.
Efficacy of spinal manipulative therapy for low back pain of less than
three months' duration. JMPT November/December 2003. Volume 26 .
Number 9. Review of the literature. Ferreira et al.
Conclusions: Spinal manipulative therapy produces slightly
better outcomes than placebo therapy, no treatment, massage,
and short wave therapy for nonspecific low back pain of less
than 3 months duration. Spinal manipulative therapy, exercise,
usual physiotherapy, and medical care appear to produce
similar outcomes in the first 4 weeks of treatment.
The Journal of Neurological and Orthopaedic Medicine and
Surgery. An article entitled, Effective Management of Spinal Pain
in 200 Patients Evaluated for Manipulation Under Anesthesia
Volume 17,No 1, 1998.
"In completing this study, the authors found that a
multidisciplinary approach to evaluation and
treatment offers patient benefits above and beyond
that which can be obtained through the individual
providers working alone.
It is our intention to proceed with studies of a more
specific design as this present work has
demonstrated positive results and no complications."
The New England Journal of Medicine
1999;341:1426-1431, 1465-1467.
Osteopaths equal MDs at relieving chronic back pain
NEW YORK, Nov 03 (Reuters Health) -- Manual therapy
by an osteopath is as effective at relieving chronic lower
back pain as traditional medical care, according to a report in
the November 4th issue of The New England Journal of
Medicine.
Results of a study from Chicago researchers showed
patients who received osteopathic therapy for subacute low
back pain received fewer drugs and needed less physical
therapy than those treated with standard care.
Reminder: DC’s provide 94% of all manipulation performed. RAND.
Randomized Osteopathic Manipulation Study (ROMANS): Pragmatic
Trial for Spinal Pain in Primary Care. Wilkinson C, et al. Family
Practice 2003. Dec;20(6):662-9
CONCLUSION: A primary care osteopathy clinic improved shortterm physical and longer term psychological outcomes, at little
extra cost. Rigorous multicentre studies are now needed to
assess the generalizability of this approach.
Reminder: DC’s provide 94% of all manipulation performed.
RAND.
Spinal manipulation effective for low back pain. Strickland. The
Journal of family practice.; 2003 Dec;52(12) p925 - 929
Spinal manipulation, usual care with analgesics, physical therapy,
exercises, and "back school" all provide similar results when
used for treatment of both acute and chronic low back pain.
Clinicians may wish to treat patients with low back pain
themselves or refer them for chiropractic care, physical
therapy, or back schools. This decision should be based on
patient preferences after reviewing relative risks and benefits.
A recent systematic review of alternative therapies for low back
pain reported similar effects from spinal manipulation and
massage therapy. The effectiveness of acupuncture in the
management of low back pain remains unclear.
Bronfort et al. Trunk Exercise Combined with Spinal Manipulation
or NSAID Therapy for Chronic Low Back Pain: A Randomized,
Observer-Blinded Trial. JMPT. Vol. 19. Number 9. Nov/Dec. 1996.
Results: There seemed to be a sustained reduction in
medication use at the 1-year follow-up in the
SMT/TSE group.
Continuance of exercise during the follow-up year,
regardless of type, was associated with a better
outcome.
Conclusion: For the management of CLBP, trunk
exercise in combination with SMT or NSAID therapy
seemed to be beneficial and worthwhile.
Cox et al. Distraction Manipulation Reduction of an L5-S1 Disk
Herniation . Journal of Manipulative and Physiological
Therapeutics Volume 16, Number 5, June, 1993
Conclusions: Chiropractic distraction manipulation is
an effective treatment of lumbar disk herniation, if
the chiropractor is observant during its administration
for patient tolerance to manipulation under
distraction and any signs of neurological deficit
demanding other types of care.
BenEliyahu et al. Magnetic Resonance Imaging and Clinical Follow-up:
Study of 27 Patients Receiving Chiropractic Care for Cervical and Lumbar
Disc Herniations. JMPT. Volume 19, Number 9, November/December,
1996
Results: Clinically, 80% of the patients studied had a good clinical
outcome with post-care visual analog scores under 2 and
resolution of abnormal clinical examination findings.
Anatomically, after repeat MRI scans, 63% of the patients
studied revealed a reduced size or completely resorbed disc
herniation. There was a statistically significant association (p,
.005) between the clinical and MRI follow-up results. Seventyeight percent of the patients were able to return to work in their
pre-disability occupations.
Conclusion: This prospective case series suggest that chiropractic
care may be a safe and helpful modality for the treatment of
cervical and lumbar disc herniations. A random, controlled,
clinical trial is called for to further substantiate the role of
chiropractic care for the non-operative clinical management of
intervertebral disc herniation.
Cassidy et al. Side Posture Manipulation for Lumbar
Intervertebral Disk Herniation. JMPT. Volume 16, Number 2,
February, 1993
Conclusions: The treatment of lumbar intervertebral
disk herniation by side posture manipulation is both
safe and effective.
Cassidy et al. Cont’d
Points of Interest:
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Normal disks withstood an average of 22.6 degrees of rotation before failure,
while the degenerated disks withstood an average of 14.3 degrees.
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When disk failure occurred, it presented as peripheral annular tears and not
herniation or prolapse.
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Posterior facet joints of the intact lumbar motion segment allow only a small
range of rotation at the lower levels.
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Therefore torsional failure of the lumbar disk first requires fracture of the
posterior joints, which can then result in peripheral annular tears.
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Bottom line: The bony architecture of the lumbar spine prevents excess
rotation that would have damaged the peripheral annular fibers. Therefore it
remains unlikely that side posture spinal manipulation would damage a disk.
Waagen et al. Short term trial of chiropractic adjustments for the
relief of chronic low back pain. Manual Medicine (1986) 2:63-67
After two weeks of treatments the experimental
patients as a group exhibited significant overall pain
relief (+2.3), whereas improvement of patients in the
control group was not significant (+0.6).
Troyanovich et al. JMPT. Vol. 21, Number 1, January 1998. Structural
Rehabilitation of the Spine and Posture: Rationale for Treatment Beyond
the Resolution of Symptoms.
Conclusion: Because mechanical loading of the
neuromusculoskeletal tissues plays a vital role in influencing
proper growth and repair, chiropractic rehabilitative care should
focus on the normalization/minimization of aberrant stresses
and strains acting on spinal tissues.
Manipulation alone cannot restore body postures or improve an
altered sagittal spinal curve. Therefore, postural chiropractic
adjustments, active exercises and stretches, resting spinal
blocking procedures, extension traction, and ergonomic
education are deemed necessary for maximal spinal
rehabilitation.
Croft et al. Outcome of low back pain in general practice: a
prospective study. BMJ Volume 316; 2 May 1998.
Conclusions: The results are consistent with the
interpretation that 90% of patients with low back
pain in primary care will have stopped consulting with
symptoms within three months.
However most will still be experiencing low back pain
and related disability one year after consultation.
Shekelle et al. Congruence between Decisions To Initiate Chiropractic
Spinal Manipulation for Low Back Pain and Appropriateness Criteria in
North America. Annals of Internal Medicine, 1 July 1998. 129:9-17.
Conclusions: The proportion of chiropractic spinal
manipulation judged to be congruent with
appropriateness criteria is similar to proportions
previously described for medical procedures; thus,
the findings provide some reassurance about the
appropriate application of chiropractic care.
However, more than one quarter of patients were
treated for indications that were judged
inappropriate. The number of inappropriate
decisions to use chiropractic spinal manipulation
should be decreased.
Mooney. Why Exercise for Low Back Pain? Activity Reverses
Biochemical Changes Caused by Injury. The Journal of
Musculoskeletal Medicine. October 1995.
Selected statements:
There is no evidence that a diagnosis-or even the presence or absence of a
neurologic deficit-can predict the duration or outcome of a back problem.
Concerning exercise and AHCPR Guidelines: The guidelines are nonspecific and
contain no rationale.
In all other soft-tissue injuries, progressive physical activity evacuates extracellular,
extravascular fluid. This justifies the recommendation of early mobility for
injured tissues. The early motion should be gentle but progressive, with the
expectation that gradually increasing stresses will facilitate healing.
Koes, et al. A Randomized Clinical Trial of Manual Therapy and
Physiotherapy for Persistent Back and Neck Complaints: Subgroup
Analysis and Relationship Between Outcome Measures. JMPT; 16:211219; 1993.
Results: Greater improvement in the main complaint
was associated with manual therapy than with
physiotherapy for patients with back problems of 1
year’s duration or longer. For patients younger than
age 40 years, improvement was also greater with
manual therapy than with physiotherapy.
Conclusion: Manual therapy appears to yield better
results than physiotherapy in patients with chronic
conditions, and in patients younger than age 40
years.
Davis. Chronic Cervical Spine Pain Treated With Manipulation Under
Anesthesia.
Journal of the Neuromusculoskeletal System. Fall 1996 Vol. 4, No. 3.
The results suggest that manipulation under
anesthesia may be beneficial in patients with
chronic pain that effects work or activities
of daily living and in patients with cervical
segmental dysfunction, fibrosis, myofascitis,
or cervicogenic headaches.
Licciardone et al. Osteopathic Manipulative Treatment for Chronic
Low Back Pain. Spine. 2003;28:1355-1362.
Conclusion: Osteopathic Manipulative Treatment (OMT) and
sham manipulation, both appear to provide some benefits when
used in addition to usual care for the treatment of chronic
nonspecific LBP.
It remains unclear whether the benefits of OMT can be attributed
to the manipulative techniques themselves or whether they are
related to other aspects of OMT, such as range of motion
activities or time spent interacting with the patient, which may
represent placebo effects.
Quon et al. Lumbar Intervertebral Disc Herniation: Treatment by
Rotational Manipulation. Journal of Manipulative and Physiological
Therapeutics, Volume 12, Number 3, June, 1989.
Although caution must be exercised in interpreting single case
studies, this paper describes a patient who presented with an
L4-L5 disc herniation. The size of the lesion revealed by CT
examination was so great that one would not expect a favorable
response to conservative measures.
However, the patient was rendered pain-free within 2 weeks by
daily manipulations.
The enormous size of the disc herniation did not seem to influence
the clinical result. Had a trial of conservative therapy not been
prescribed, he may well have undergone an unnecessary
surgical procedure. Furthermore, a repeat CT scan, 4 months
after the initial episode, showed no change in the size or
position of the disc herniation.
Miscellaneous Literature Providing a
Rationale Basis for a Consensus
Statement Concerning Supportive
Care of Chronic Pain Conditions
“Passive” or “No lasting therapeutic Benefit” or
“Non-Curative” or “Palliative”
What treatment can survive a requirement suggesting that treatment must
provide curative or long lasting therapeutic benefit? ANSWER: NONE!
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Chiropractic or Osteopathic manipulation
Drugs
Physical Therapy (electric stim, ultrasound, ice, heat, etc.)
Massage
Epidural injections
Facet Injections
Physical Rehabilitation
Exercises
Patient Education
NSAIDs
Surgery
Criteria: Minimal requirements to qualify for
Chronic Pain Management.
1.
2.
3.
4.
5.
6.
Unable to attain pre-accident status; attained
maximal therapeutic benefit; recovered with
residual soft tissue damage
Therapeutic withdrawal attempted
Unable to maintain improvement
Minimal tx recommended
Dx & Tx alternatives considered
Home management recommended
Goals of Chiropractic Spinal Manipulation
for Chronic Pain
1.
2.
3.
4.
Pain Relief
Improve Fx
Decrease Reliance on drugs
Keep the patient employed
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
Joints
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Shrinks joint capsules
Increases compressive loading
Leads to joint contracture
Increases synthesis rate of glycosaminoglycans
Increase in periarticular fibrosis
Irreversible changes after 8 weeks of immobilization
Ligament
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Lowers failure or yield point
Decreased thickness of collagen fibers
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
(cont’d)
Disk Biochemistry
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·
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Decreases oxygen
Decreases glucose
Decreases sulfate
Increases lactate concentration
Decreases proteoglycan content
Bone
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Decreases bone density
Eburnation
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
(cont’d)
Muscle
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Decreased thickening of collagen fibers
Decreased oxidative potential
Decreased muscle mass
Decreased sarcomeres
Decreased cross-sectional area
Decreased mitochondrial content
Increased connective tissue fibrosis
Type 1 muscle atrophy
Type 2 muscle atrophy
20% loss of muscle strength per week
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
(cont’d)
Cardiopulmonary
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Increased maximal heart rate
Decreased VO2 max
Decreased plasma volume
What Are The Positive Effects of Spinal Manipulation and
Joint Mobility?
Nelson, DC. Top Clin Chiro 1994;1(4):20-29.

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
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


Stretching of abnormally tight tissues (passive
forcing)
Increased range of motion
Selective tearing of adhesions without damaging
healthy tissue
Stimulation of wound healing
Improved edema removal due to pumping action of
movement
Removal of waste products & chemical mediators of
pain
Increased fluid flows, discal & cartilage nutrition
What Are The Positive Effects of Spinal Manipulation and
Joint Mobility?
Nelson, DC. Top Clin Chiro 1994;1(4):20-29.







Reduction of the pain-spasm cycle
Increase of mechanoreceptive input due to increased
motion
Close the “gate” to the central transmission of pain
Regeneration of functional tissue & less scarring
Improved rate & endpoint of tissue healing
Movement is a specific stimulus for collagen
production
Movement increases cellular metabolism & protein
synthesis
What Are The Positive Effects of Spinal Manipulation and
Joint Mobility?
Nelson, DC. Top Clin Chiro 1994;1(4):20-29.





Improved ligament strength
Improved matrix organization
Proper alignment of new collagen
Normalize proprioceptive patterns from joints &
muscles
Normalize coordinated complimentary motor
programs
Miscellaneous Literature
Adjustments Don’t Have to Make Noise to Work. Archives of
Physical Medicine and Rehabilitation – July 2003;84:1057-60.
“There is no relationship between an audible pop during
SI region manipulation and improvement in ROM,
pain, or disability in individuals with non-radicular
LBP. Additionally, the occurrence of a pop did not
improve the odds of a dramatic improvement with
manipulation treatment.”
Doctors of Chiropractic More Qualified Than Osteopaths, PTs and
MDs in Spinal Manipulation/Adjustment, According to American
Chiropractic Association. Arlington, Va., Nov. 4 /PRNewswire
* A survey of osteopathic schools found that most schools generally offer
spinal manipulation/adjustment only on an elective basis.
* No manipulation/adjustment training is given or available for M.D.s in
medical school curricula.
* One study queried 10 physical therapy schools -- none taught spinal
manipulation/adjustment.
"Individuals with less training and expertise than doctors of chiropractic
may provide outcomes that are less than optimal, and can pose
unnecessary health and safety risks and possible complications for
patients," the policy statement reads.
Exercise? Is it a cure-all?
Several studies compared McKenzie (exercises) protocols with
spinal manipulation.

Wiesel, MD (Cherkin, PhD) McKenzie Protocol versus
Chiropractic Care for LBP. Backletter
1995:10(11):121, 130, 131.
And

Wiesel, MD. (Cherkin, PhD) Mckenzie versus
Manipulation. Back letter 1996;11(12)Dec: 133, 139.
Exercise

“McKenzie and spinal manipulation were equivalent
in symptoms, function, disability, and satisfaction,
and were superior to booklet in terms of symptoms
and satisfaction. However, McKenzie did not reduce
recurrences or long-term utilization of health care.”

In other words, exercise is no cure in and of itself for
the treatment of low back pain.
Chronic Back Pain Survey
“Survey: Chronic back pain sufferers prefer drug-free pain
management.” ACA press release. 8/20/2004






71% had suffered chronic LBP for 5 years or more.
84.6% had suffered back pain for a minimum of 3 years.
Most common remedy…drugs…41% reported back pain was
“not under control”, or “not under control at all”.
64.4% would consider consulting a DC for LBP.
80.3% would prefer to avoid the use of medication.
Highest income respondents were the group least likely to
prefer using medications for their back pain.
Observation: DC profession must do a better job of promoting itself as a
provider of safe, natural, drug-free methods of pain relief…and not just for back
pain.
Wiberg et al. The Short-term Effect of Spinal Manipulation in the
Treatment of Infantile Colic: A randomized Controlled Clinical Trial with a
Blinded Observer. Journal of Manipulative and Physiological Therapeutics
Volume 22, Number 8, October 1999.


Results: By trial days 4 to 7, hours of crying were
reduced by 1 hour in the dimethicone group
compared with 2.4 hours in the manipulation group
(P=.04). On days 8 through 11, crying was reduced
by 1 hour for the dimethicone group, whereas crying
in the manipulation group was reduced by 2.7 hours
(P=.004). From trial day 5 onward the manipulation
group did significantly better than the dimethicone
group.
Conclusion: Spinal manipulation is effective in
relieving infantile colic.
Reed et al. Chiropractic Management of Primary Nocturnal Enuresis.
JMPT, Volume 17, Number 9, November/December, 1994
Results: The post-treatment mean wet night frequency of 7.6
nights/2 wk for the treatment group was significantly less than
its baseline mean wet night frequency of 9.1 nights/2 wk (p =
0.05). For the control group, there was practically no change
(12.1 to 12.2 nights/2 wk) in the mean wet night frequency
from the baseline to the post-treatment………
Twenty-five percent of the treatment-group children had 50% or
more reduction in the wet night frequency from baseline to
post-treatment while none among the control group had such
reduction.
Conclusion: Results of the present study strongly suggest the
effectiveness of chiropractic treatment for primary nocturnal
enuresis.
Maigne et al. Highlighting of Intervertebral Movements and Variations of
Intradiskal Pressure During Lumbar Spine Manipulation: A Feasability
Study. JMPT Vol. 23, Number 8, October 2000.
Even though this study was a limited one on cadavers, it has important implications:
- Spinal manipulation is capable of lowering intradiscal pressure, a phenomenon
thought to improve related symptoms.
- This pressure change theory is consistent with outcome studies that have
examined manipulation in the treatment of symptomatic disc herniation.
- Vertebral movement can be demonstrated during manipulation.
- The effect of this movement is to redistribute or normalize intradiscal pressure,
not to result in a different resting position of the vertebra.
- Future work on the motion/position aspect of manipulation should look at
temporary positional changes during the manipulation, not before and after
position.
Maigne et al. Cont’d
Conclusion: Lumbar spinal manipulations have a
biomechanical effect on the IVD, producing a brief
but marked change in intradiskal pressure. This
effect, which differs slightly with the different types
of manipulation studied, is the consequence of
movements of the adjacent vertebrae.
Chiropractic management of chronic chest pain using mechanical force,
manually assisted short-lever adjusting procedures. Polkinghorn BS, Colloca
CJ. J Manipulative Physiol Ther. 2003 Feb;26(2):108-15
OBJECTIVE: To discuss a case involving a patient with chronic chest pain, dyspnea, and anxiety. Although
resistant to previous treatment regimens, the condition responded favorably to chiropractic manipulation of
the costosternal articulations.
METHODS: 49 year old male, chronic chest pain for 4 months, Activator instrument,
RESULTS: After 14 weeks of care, complete resolution of chronic pain, maintained at 9 month follow-up,
CONCLUSIONS: Certain types of chest pain may have their etiology in a subluxation complex involving
the costosternal articulation.
….. a musculoskeletal involvement, including costosternal subluxation complex, may be the underlying
cause of the symptoms in certain patients. When this is the case, chiropractic adjustment may provide an
effective mode of treatment.
Chiropractic high-velocity low-amplitude spinal manipulation in the
treatment of a case of postsurgical chronic cauda equina syndrome. Lisi
AJ, Bhardwaj MK. J Manipulative Physiol Ther. 2004 Nov-Dec;27(9):574-8.
OBJECTIVE: To present an evidence-based case report on the use of chiropractic high-velocity lowamplitude spinal manipulation in the treatment a postsurgical, chronic cauda equina syndrome patient.
METHODS: 35 yr old female, presents with CES, duration of symptoms-6 months-post surgical for acute
CES secondary to HNP; symptoms considered to be residual and non-progressive.
INTERVENTION AND OUTCOME: Pt. Tx with HVLA CMT and ancillary myofascial release. After 4
treatments, the patient reported full resolution of midback, low back, and buttock pain. The patient was seen
another 4 times with no improvement in her neurologic symptoms. No adverse effects were noted.
CONCLUSION: This appears to be the first published case of chiropractic high-velocity low-amplitude
spinal manipulation being used for a patient with chronic cauda equina syndrome. It seems that this type of
spinal manipulation was safe and effective for reducing back pain and had no effect on neurologic deficits in
this case.
Nonoperative treatments for sciatica: a pilot study for a randomized clinical
trial.Bronfort G, Evans RL, Anderson AV, Schellhas KP, Garvey TA, Marks RA, Bittell S. J
Manipulative Physiol Ther. 2000 Oct;23(8):536-44. Related Articles, Links
OBJECTIVES: To assess the feasibility of patient recruitment, the ability of patients and clinicians to
comply with study protocols, and the use of data collection instruments to collect cost-effectiveness data, and
to obtain variability estimates for sample-size calculations for a full-scale trial.
PATIENTS: Ages 20 to 65 years, with low back-related radiating leg pain (sciatica), tx with Medical care,
chiropractic care, and epidural steroid injections.
OUTCOME MEASURES: Self-report questionnaires were administered at baseline and 3 and 12 weeks
after randomization.
RESULTS: A total of 706 persons were screened by phone to determine initial eligibility. Of these, over
90% of those persons contacted did not meet the entrance criteria. The most common reason for
disqualification was that the duration of the complaint was longer than 3 months.
CONCLUSIONS: Pilot studies such as these are important for the determination of the feasibility of
conducting costly, larger scale trials. Recruitment for a full-scale study of sciatica of 2 to 12 weeks duration
is not feasible.
Vernon et al. Spinal Manipulation and Headaches of Cervical Origin.
Journal of Manipulative and Physiological Therapeutics, Volume 12,
Number 6, December, 1989.
ABSTRACT: The role of the cervical spine in headache remains
controversial. Often confused as tension or common migraine
headache, headaches arising from the neck pose a diagnostic and
therapeutic challenge.
Recent writers addressing this issue, including Bogduk (2-4), Edmeads
(50, Farina et al. (6) and Sjaastad and his colleagues (7-9), have
added much to our current understanding. However, even these
authors appear to have included only a small portion of the supportive
literature in their reports, leaving a diminished sense of the historical
attention and the current clinical importance of this category of
headaches.
Chiropractic
Cost Related Literature and
Information
Cost Issues
What is the financial impact of
Chiropractic Healthcare? What is
the impact of medical errors and
drug shadow costs?
Research…
oldies but goodies!
A review of past literature.
Topic: Bed Rest
Waddell. A New Clinical Model for the Treatment of Low-Back
Pain. Spine. 1987;12:632-644



Little scientific or clinical evidence supports the value
of bed rest.
Only four controlled studies
Bed rest is the most harmful treatment ever devised
and a potent cause of iatrogenic disease.
Topic: Bed Rest
AHCPR. Lee. Publication No. 95-0643; December 1994, pp. 2.
Extended bed rest could be harmful. Resting in bed
for more than 4 days can weaken muscles and bones
and delay recovery.
RAND Study
Shekelle, et al. “The Appropriateness of Spinal Manipulation for
Low Back Pain: Indication and Ratings by a Multidisciplinary
Expert Panel.” 1991; RAND/UCLA Monograph No. R-4025/2CCR/FCER.
“Spinal manipulation is the most commonly used conservative treatment
for back pain supported by the most research evidence of effectiveness
in terms of early results and long-term effectiveness.”
2/3 of patient visits were to chiropractic providers for a total cost
of $2.4 billion in 1988. Conversely, 1/3 of the visits for back
pain were to medical providers (MD) for a total cost of $8
billion.
94% of manipulation is performed by doctors of chiropractic.
AHCPR
Acute Low Back Problems in Adults: Assessment and Treatment
Proven Initial Care: Patient education, patient comfort
(NSAIDs), and SPINAL MANIPULATION.
Unproven Therapies: Traction, physical modalities
(massage, diathermy, US, cutaneous laser,
biofeedback, TENS, acupuncture, trigger point
injections, facet injections, steroid or lidocaine
injections, shoe lifts, exercise machines, stretching.
Harmful treatment: Best Rest.
Utah Study
Jarvis, et al. Cost per Case Comparison of Back Injury Claims of
Chiropractic Versus Medical Management for Conditions with
Identical Diagnostic Codes. Journal of Occupational Medicine.
1991; Vol. 33, No. 8, Aug., pp. 847-851.
In 3,062 separate cases:


Chiropractic care took an active
approach with 8 times more visits.
Medical care took a passive approach
prescribing medication and rest.
Utah Study
(cont’d)
Conclusion:




Chiropractic care was 73% more cost-effective per
case.
The average distribution cost per office visit was 67%
less for chiropractic than for the medical office visit.
Patients seeing doctors of chiropractic were able to
return to work 10 times sooner than those under
medical care.
For the total data set, cost for care was significantly
more for medical claims—Compensation costs were
ten-fold less for chiropractic claims.
Australian Study
Ebrall. Mechanical Low Back Pain: A Comparison of Medical and
Chiropractic Management Within the Victorian WorkCare Scheme.
Chiropractic Journal of Australia. 1992; Vol. 22, No. 2, June pp.
47-53

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

Compensation days with Chiropractic management
are ¼ the days of claims with medical management.
The “occurrence of chronicity” was greater with
medical management (6 fold greater progression to
chronicity-11.6% to 1.9%).
Cost of claims: $2,038 Medical/$963 Chiropractic.
Average compensation payment is 4 times greater
with medical management.
Australian Study
(cont’d)
Conclusion: Financial and social savings could
be maximized by:


Increased participation rate by DCs in the WorkCare.
Increased early referral from medical doctors to
Chiropractic doctors.
British Study
Meade, et al. Low Back Pain of Mechanical Origin. Randomized
Comparison of Chiropractic and Hospital Outpatient Treatment.
BMJ. 1990; Vol. 303, No. 6737. June pp. 1431-1437


10 year multicenter trial.
Conclusion:




Chiropractic treatment was significantly more effective,
particularly with patients with chronic and severe pain.
Results were long-term throughout the two-year follow up
period.
The potential economic, resources, and policy implications of
the results were extensive.
Patients treated by Chiropractors…almost certainly
fared considerably better and maintained their
improvement for at least two years.
Canadian Study
Manga et al. The Effectiveness and Cost Effectiveness of
Chiropractic Management of Low-Back Pain. Manga Report to
Ontario Ministry of Health. August, 1993.
Conclusions: The “Constellation of evidence” demonstrates:





The treatment effectiveness and cost effectiveness of
Chiropractic care.
The untested, questionable, or harmful nature of
many current medical therapies.
The economic efficiency of Chiropractic care versus
medical care.
The safety of Chiropractic.
Higher patient satisfaction.
Canadian Study
Manga (cont’d)
Summary:
There should be a shift in policy to encourage
the utilization of chiropractic services for most
patients with back pain…
A very good case can be made for making
chiropractors the gatekeepers for
management of low-back pain the worker’
compensation system.
Virginia Study
Schifrin. Mandated Health Insurance Coverage for Chiropractic
Treatment: An Economic Assessment with Implications for the
Commonwealth of Virginia. January, 1992



“By every test of cost-effectiveness, the general
weight of evidence shows that Chiropractic provides
important therapeutic benefits at economical costs.”
“These benefits are achieved with minimal, even
negligible, impact on the costs of health insurance.”
“Chiropractic services are widely used and
appreciated by a growing segment of Americans.”
2nd Virginia Study
Dean, et al. “A Comparison of the Cost of Chiropractors versus
Alternative Medical Practitioners.” Virginia Chiropractic
Association. January 1992.



“Chiropractors see their patients more frequently but
have lower overall costs for most of the conditions
considered.”
“Chiropractic care requires fewer referrals for
specialists and outside procedures.”
“If Chiropractic care is insured to the same extent as
other specialties, it may result in a decrease in overall
treatment costs for neuro-musculoskeletal
conditions.”
Medstat Project
Stano et al. MEDSTAT Data Base Review. The Journal of
American Health Policy. 1992; Vol. 2 #6.
Conclusions:


Plans which have limited or no chiropractic coverage
have the highest total costs per patient.
Broader coverage of chiropractic services results in
dramatically lower health care cost as follows:
35% lower hospital admission rates.
42% lower inpatient payments.
23% lower total health care costs.
US General Accounting Office
“Access to Health Insurance: State Efforts to Assist Small
Business.” GAO-92-90; May 1992; pg. 33

“Mandates determined not to add significantly to the
cost of health insurance include services for in-vitro
fertilization, acupuncture, and cleft palate, as well as
services provided by Chiropractors and home health
nurses. It is these low cost mandates, however that
are often cited by the business community as
examples of the added wasteful expense mandates
cause for business.”
Journal of American Health Policy
Stano et al. “The Growing Role of Chiropractic in Health Care
Delivery.” Journal of American Health Policy. 1992 Nov-Dec. pp.
39-45.


“Plans which do not cover Chiropractic have the
highest payments per patient.”
“Increased availability of demonstrated cost-effective
alternatives would increase access and would reduce
costs.”
Journal of Family Practice
Cherkin et al. “Family Physicians, Chiropractors, and Back Pain.”
The Journal of Family Practice. 1992; Vol. 35, No. 5, pp. 551-555

Chiropractic doctors are well-trained
and well-accepted by both patients and
insurers.
Western Journal of Medicine
Cherkin et al. “Patient Evaluation of Low Back Pain Care from
Family Physicians and Chiropractors.” Western Journal of
Medicine. 1989; Vol. 150, No. 3, March pp. 351-355.
Conclusion:



Chiropractic doctors were highly rated compared to
medical doctors in critical patient care areas for the
treatment of low back pain.
Patients gave DCs a 3:1 advantage in five important
areas of patient satisfaction.
Chiropractic patients reported quicker recoveries.
British Medical Journal
Smith. “Where is the Wisdom? The Poverty of Medical Evidence.”
BMJ. 1991; Vol. 303, October pp. 798-799.
“Only about 15% of medical
interventions are supported by valid
medical evidence…Many treatments
have never been assessed at all.”
Recent studies…
A review of the literature.
“DC’s as Primary Care Providers”
(Interview with James Zechman, Part 1, condensed summary)
Editor’s note: In the December 1, 1999 issue, we
interviewed the CEO of Alternative Medicine, Inc.
(AMI), James Zechman. AMI had contracted with
Blue Cross/ Blue Shield of Illinois, the state’s largest
managed care plan, to give its more than 700.000
enrolled members the option of having AMI’s
chiropractors as their primary care physicians.
The following interview highlights were reported in the
February 12, 2001issue of Dynamic Chiropractic.
Zeckman (cont’d)
Our theory was to accurately test a preventive health
care system based on a non-pharmaceutical/nonsurgical entry point.
We have no limit on the number of visits, treatments or
procedure. Anything which takes place within the
doctor’s own office is unencumbered.
Zeckman (cont’d)


Waiting to see a physician until disease is present adds costly
tests, procedures and pharmaceuticals to health care bill that
could have been avoided through a strong and integrated
preventive care program.
We believe this is the only rational choice: to create a true
prevention-based health care system as opposed to after-thefact disease care system. It is this system of truly integrated
medicine that precludes the need for restrictive guidelines and
disruptive oversight of chiropractic care. We believe once you
identify quality- the rest takes care of itself.
Zeckman…The Results

Compared to normative values in the greater Chicago area for
all other allopathic IPA’s our network has reduced
hospitalizations by approximately 60 percent over a 24-month
consecutive period.

We have reduced outpatient surgery and procedures by
approximately 85 percent over a 24- month consecutive
period.

We have reduced pharmaceutical usage by approximately 56
percent over a 24-month consecutive period.

Of interest to note is that we have no C-section deliveries over
a two-year period, as compared to a network average of over
22 percent.
Zeckman…Conclusion


AMI’s primary care chiropractors are showing
the world what the profession has always
believed since its inception:
Chiropractic has an ability to impact a
person’s health in a very profound manner.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
Retrospective study of patients at an independent
physician model HMO in Louisiana evaluating cost of
care for acute low back pain or neck pain for patients
who sought chiropractic care or other treatment. Also
looked at surgical rates, use of diagnostic imaging (MR
and CT) and patient satisfaction on claims paid Oct. 1,
1994 – Oct. 1, 1995.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
Results: Cost of care for BP and NP was substantially lower for DC
patients than non-DC patients.
Use of prescription drugs and
diagnostic imaging were significantly greater in non-DC group
whereas surgical rates and patient satisfaction were nearly identical.
Conclusion: DC care outcomes are equal to those of non-DC care at
substantially lower costs. MD patients got 2x as many prescriptions.
Study demonstrates that DC services were well integrated in an HMO
and has proven satisfactory to patients and providers as well as costeffective for BP and NP. The system offered self-referral for DC
services.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
If half of the patients treated by traditional care received DC
care, annual savings would have exceeded $215,000. We
recommend its wider application by the managed care
industry and physician community. [Emphasis Added.]
Muse Study\Medicare
The Muse study compared the most recently available
CMC Medicare cost and utilization data for those
beneficiaries that received chiropractic care versus
those beneficiaries that only received traditional
medical care. The Muse study found that the
global per capita Medicare expenditures for
chiropractic patients were significantly lower
than the same costs for non-chiropractic
patients.
Muse Study\Medicare
(cont’d)
The Muse study concluded,
"Chiropractic care significantly reduces per
beneficiary costs to the Medicare program. The
results of the study suggests that chiropractic
services could play a role in reducing costs
Medicare reform and/or a new prescription
drug benefit."
Comparative Analysis of Individuals With and Without Chiropractic
Coverage Patient Characteristics, Utilization, and Costs. Legorreta, Metz,
Nelson, Ray, Chernicoff, DiNubile, MD Arch Intern Med. 2004;164:1985-1992.
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).
Less total annual health care costs at the health plan level.
Lower utilization (per 1000 episodes) of plain radiographs
Less low back surgery
Less hospitalizations
Less magnetic resonance imaging.
Lower average back pain episode–related costs ($289 vs $399, P<.001).
“Chiropractic Care: is it substitution care or add-on care in
corporate medical plans?” Metz, et al. J. Occupational
Environmental Medicine. 2004;46:847-855.






The results “indicate that patients use chiropractic care as a
direct substitute for medical care.”
4 year study: 1997-2001
Not a survey….used actual claims data.
1,394,070 patients; 174,209 were DC pts; 332,548 were
medical pts; 887,313 were medical pts w/o DC coverage.
Results: nearly half chose DC care when offered a choice.
“Within a MC setting, the inclusion of a DC benefit does not
increase the overall rates of pt. complaints….pts appear to be
directly substituting DC care for medical care”.
“An Evaluation of Medical and Chiropractic Provider Utilization and Costs:
Treating Injured Workers in North Carolina JMPT September 2004 • Volume
27 • Number 7 Shawn P. Phelan, DC, Richard C. Armstrong, DC, David G. Knox, DC,
Michael J. Hubka, DC, Dennis A. Ainbinder, MD




Objective: To examine utilization, treatment costs, lost workdays, and
compensation paid workers with musculoskeletal injuries treated by medical
doctors (MDs) and doctors of chiropractic (DCs).
Design: Retrospective review of 96,627 claims between 1975 and 1994.
Results Average cost of treatment, hospitalization, and compensation payments
were higher for patients treated by MDs than for patients treated by DCs.
Average number of lost workdays for patients treated by MDs was higher than
for those treated by DCs. Combined care patients generated higher costs than
patients treated by MDs or DCs alone.
Conclusion These data, with the acknowledged limitations of an insurance
database, indicate lower treatment costs, less workdays lost, lower
compensation payments, and lower utilization of ancillary medical services for
patients treated by DCs. Despite the lower cost of chiropractic management, the
use of chiropractic services in North Carolina appears very low.
Drug Issues
Miscellaneous Literature
Gurkirpal Singh, George Triadafilopoulos, Epidmiology of NSAID induced
gastrointestinal complications. J. Rheumatol 1999, Apr;26 Suppl 56:18-24.
Department of Medicine, Division of Immunology, Stanford University
School of Medicine, Palo Alto, California 94304, USA.


NSAIDs are one of the most commonly used classes of
medications worldwide. 30 million people take NSAIDs daily.
GI complications are the most prevalent category of adverse
drug reactions. Patients with arthritis are the most frequent
users, therefore at greater risk.
NSAID related deaths among patients with RA and OA are even
more startling. It is conservatively estimated that 16,500
NSAID-related deaths occur in these patients every year
in the US.

15th most common cause of death in the US.

Stats DO NOT include nonarthritis indications.
Wolfe, M.D., Lichtenstein, M.D., Singh, M.D.
Gastrointestinal Toxicity of Nonsteroidal Antiinflamatory Drugs. The New
England Journal of Medicine, June 17, 1999, Review Article, Medical
Progress.





113 References.
NSAID agents constitute one of the world’s most widely used classes of drugs,
with more than 70 million prescriptions and more than 30 billion over-thecounter tablets sold annually in the US.
“Although the annual mortality rate is low, it must be emphasized that because
a large number of patients are exposed to NSAIDs often for extended periods of
time, the risk over a lifetime is substantial.”
Hospitalization due to GI complications 103,000/yr. Estimated cost $15,000 to
$20,000 per hospitalization. Annual cost exceeds $2 Billion.
“It has been estimated conservatively that 16,500 NSAID-related
deaths occur among patients with RA and OA every year in the US.”
Wolfe, M.D., Lichtenstein, M.D., Singh, M.D.
Gastrointestinal Toxicity of Nonsteroidal Antiinflamatory Drugs. The New
England Journal of Medicine, June 17, 1999, Review Article, Medical
Progress. (cont’d)





Doses of aspirin as low as 30 mg are sufficient to suppress prostaglandin
synthesis in the gastric mucosa initiating gastric-duodenal mucosal injury,
resulting in the release of oxygen-derived free radicals.
Peptic ulcers-gastroduodenal hemorrhage-perforation-death!
Acetaminophen is nontoxic to the GI mucosa, however, recall that
acetaminophen is a leading cause of end-stage renal disease.
Cox-2 inhibitors will hopefully have a reduced capacity to cause injury to the
gastroduodenal mucosa.
However, Cox-2 inhibitors are also known to cause defects in renal function,
alter the regulation of bone resorption, impair female reproductive physiology,
and increase the rate of thrombotic events in patients with increase risk for
cardiovascular disease.
Dabbs, D.C. and Lauretti, D.C., A Risk Assesment of Cervical
Manipulation vs. NSAIDs for the Treatment of Neck Pain. Journal of
Manipulative and Physiological Therapeutics. Vol. 18, number 8
Oct. 1995; 18:530-6.
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“The best evidence indicates that cervical manipulation for neck
pain is much safer than the use of NSAIDs, by as much as a
factor of several hundred times. There is no evidence that
indicates NSAID use is any more effective than cervical
manipulation for neck pain.”
Death rate for NSAID-associated GI problems at 0.04% per yr
amoung OA patients receiving NSAIDs, or 3,200 deaths in the
US per year.
He (Brandt) also noted that there are several animal studies and
human clinical studies that have actually implicated NSAIDs in
the acceleration of joint destruction.
OxyContin



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
U.S. News and World Report, July 2, 2001
“Not an appropriate use”, “Did the makers of
OxyContin push too hard?”
Virginia residents filed a $5.3 billion class action
lawsuit that alleges Pharma also failed to disclose the
drug’s risks, setting off a wave of OxyContin
addiction and abuse.
Associated deaths jumped 93% between 1997 and
1998.
DEA reported 291 deaths in just 6 states.
NUTLEY, N.J. (July 15) - Mother's little
helper is not so little anymore.



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Valium, the drug that revolutionized the
treatment of anxiety and became a cultural
icon, is 40 years old this year.
Invented by chemist Leo Sternbach
Approved for use in 1963, became the
country's most prescribed drug from 1969 to
1982.
The Roche Group, Hoffman-La Roche's
parent, sold nearly 2.3 billion pills
stamped with the trademark ``V'' at its
1978 peak.
Baycol-Cholesterol drug




The Columbus Dispatch, August 9, 2001
“Bayer pulls medicine tied to 31 U.S.Deaths”
Baycol has been linked to significantly more fatal
cases than its competitors, Dr. John Jenkins of the
FDA
Other drugs include Lescol, Lipitor, Mevacor,
Pravachol, Zocor
Baycol-Cholesterol drug


“Every statin has been linked to very rare reports of
the muscle side effect called rhabdomyolysis.”
Baycol is the 12th prescription drug taken off the
market since 1997.
Allergy Pills Overused



Study out of OSU, reported in Columbus Dispatch,
Monday, April 9, 2001
Of 246 North Carolina residents taking prescription
antihistamines, blood tests showed 65 percent didn’t
have allergies.
Skill testing unreliable vs. Blood tests
“Side Effects: As Drug-Sales Teams Multiply, Some
Doctors Shut Them Out”

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Wall Street Journal, 6-13-03
“’Arms Race’ by Pfizer, Rivals Boost Pill Prices and
Ire, But No One Dares Retreat.”
“Free Tacos and Piles of Bextra”
90,000 drug industry reps
$12 Billion spent on sales force
$2.76 billon on consumer drug ads.
Result: Prescriptions up 14% to $161 Billion spent on
drugs in 2002!!!!
Unnecessary Mastectomies


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
BMJ March 4, 2000
1997 pathologist Professor Kemnitz made numerous
false positive diagnoses of breast cancer.
300 women suffered mastectomies
Professor Kemnitz committed suicide, set himself on
fire and destroyed evidence in
his lab.
Wall street journal,4/22/03 Page 1, section d
Saying No to the Knife...


Apparently, research now shows that surgery for
back problems, gum disease, hernias, sinus
problems, and injured kidneys, to name a few, are
not necessary much of the time.
And the effects of the surgery are apparently often
worse than the condition treated.
Antibiotics and Breast Cancer
February 17, 2004 JAMA
The longer that women took the drugs, and the more
prescriptions they took, the greater their risk of
breast cancer.
Aspirin in Gastric Ulcer

76 year old women

NEJM Levy MD, Vol. 343 Number 12


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400 mg. Etodolac 2x/day for RA
1 tablet of enteric-coated aspirin / day
1 mg. of warfarin sodium per day
Endoscopy revealed aspirin tablet intact with an ulcer
of gastric antrum.
Continuous Low-Level Heat Wrap Therapy Provides More Efficacy Than
Ibuprofen and Acetaminophen for Acute Low Back Pain
Scott F. Nadler, DO, et al. SPINE 2002;27:1012-1017
Conclusion. Continuous low-level heat
wrap therapy was superior to both
acetaminophen and ibuprofen for
treating low back pain.
Muscle Relaxants
“Muscle Relaxants: Overused, Ineffective and
Acute LBP”
Bernstein E, Carey TS, Mills Garrett J. The use of muscle relaxant
medications in acute low back pain. Spine 2004;29(12):1346-51.

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Cohort of 1600..MC-LBP.
…while muscle relaxant use was quite common among patients
with acute LBP, the drugs did not help patients return to normal
functioning more quickly than patients not taking muscle
relaxants, and in fact, were associated with an increase in
the time it took for patients to recover from pain.”
Return to functional recovery: 16.2 days vs. 32.4 days ( m.
relaxants)
The Problem!
The Dangers of Modern
Medicine
Medical Mistakes: The 3rd
Leading Cause of Death





JAMA, July 26, 2000 Vol. 284. No. 4
225,000 deaths/yr = 3rd leading cause
of death
3rd only to heart disease and cancer!!
Estimates are for death only and do not
include adverse effects associated with
disability or discomfort.
Estimates are low!
Epidemiology



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
BMJ March 4, 2000
44,000 to 98,000 unnecessary
deaths/yr and 1,000,000 excess
injuries.
Clinicians inexperienced
New procedures introduced
Extremes of age, complex care, urgent
care, and prolonged hospital stay
Medical Errors




JAMA, July 26, 2000 Vol. 284. No. 4
44,000 to 98,000 die/yr - Medical errors
Of 13 countries, US ranks 12th of 16
indicators (second from the bottom!)
WHO ranked US 15th of 25
industrialized countries
Medical Errors-Patient Risks

“Blunders take 400,000 lives every year, Kaiser head says”
(By Robert A. Rosenblatt, LOS ANGELES TIMES Oakland Tribune,
July 15, 1999)



"Mistakes alone kill more people each year than tobacco,
alcohol, firearms or automobiles."
"If passengers were asked to fly with a commercial airline
organized like most health care, they wouldn’t get on the
plane.“
Kaiser is the US’s largest HMO. The 400,000 deaths per year
caused by medical mistakes is the largest number I have seen
in print so far.
JAMA - Hospital Deaths
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JAMA, July 26, 2000 Vol. 284. No. 4
12,000 deaths/yr - unnecessary surgery
7,000 deaths/yr - medication errors in
hospitals
20,000 deaths/yr - other hospital errors
80,000 deaths/yr - nosocomial infections
106,000 deaths/yr - adverse rxn, nonerror
225,000 deaths/yr - iatrogenic causes
Let’s Talk About Error




BMJ March 2000
While reading this article, 8 injured and
one will die.
Likelihood of injury at least 3% in hosp.
“Reported error rates would go up since
we underreport errors and near misses
by a factor of 10.”
Results of Errors


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JAMA, July 26, 2000 Vol. 284. No. 4
116 million extra physician visits
77 million extra prescriptions
17 million emergency department visits
8 million hospitalizations
3 million long-term admissions
199,000 additional deaths
$77 billion in extra costs
Error Underreporting



BMJ March 4, 2000
100,000 deaths with many more
incurring injuries at an annual cost of
$9 billion.
“Underreporting of adverse events is
estimated to range from 50%-96%
annually.”
BMJ Statistics




BMJ March 2000
100,000 preventable deaths per year in US
according to the Institute of Medicine
Exceeds the combined deaths and injuries
from motor and air crashes, suicides, falls,
poisonings, and drownings.
Australia produced even higher rates of error.
Errors in the Elderly


BMJ March 4, 2000
“Preventable adverse events were more
common among elderly patients,
probably because of the clinical
complexity of their care rather than age
based discrimination.”
Respectfully submitted by:
Ronald J. Farabaugh, D.C.,
CCGPP Committee Member
2879 East Dublin-Granville Rd.
Columbus, OH 43231
614-898-0787
email: [email protected]
website: www.chirocolumbus.com
website: www.chiroltd.com
(for information concerning “The Medical Referral System ™” and
other products designed to improve your practice.)
Copyright Protection Statement
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protection and may not be reproduced in any format
without the expressed written consent of Dr. Ronald
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