Chiropractic: Evidence-Based Modern Scientific Resources and Other Articles

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What happens in a typical state BCBS plan when chiropractors are the first contact provider compared to MDs for patients with low back pain? This has been studied with the Tennessee BCBS plan and results published in a peer-reviewed journal. Costs were 40% less when patients started care with a chiropractor compared to an MD. The proof is in: Putting chiropractors in charge of low back pain saves money.

Click here to read the full study published in the Journal of Manipulative and Physiological Therapeutics in 2010. At the time the study was performed, according to a personal communication to Dr. Immerman from one of the study's authors, there were no limits on the number of chiropractic visits. Tennessee BCBS now has a utilization review system for chiropractic care that allows up to about 20 visits for an acute condition, and 30+ visits for a chronic or complicated condition. Click here to read the Tennessee Chiropractic Utilization Review Guidelines which are far more liberal than the Arizona BCBS ASH guidelines.


What happens when you add chiropractic care to a large health plan like AHCCCS? This has been thoroughly researched and here is the answer: Reduced surgeries, hospitalizations, MRIs, x-rays and overall back care costs. Here is the evidence:

"Comparative Analysis of Individuals With and Without Chiropractic Coverage," Patient Characteristics, Utilization, and Costs. Antonio P. Legorreta, MD, MPH; R. Douglas Metz, DC; Craig F. Nelson, DC, MS; Saurabh Ray, PhD; Helen Oster Chernicoff, MD, MSHS; Nicholas A. DiNubile, MD. Archives Internal Medicine 2004;164:1985-1992.

ABSTRACT

Background  Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations. This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal-specific consumption of health care resources within a large managed-care system.

Methods  A 4-year retrospective claims data analysis comparing more than 700 000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit.

Results  Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year, P<.001). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared withthose without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode–related costs ($289 vs $399, P<.001).

Conclusions: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.

Click here to link to the full article at the publisher site.


What happens when chiropractors become primary care physician (PCP) gatekeepers? This has been thoroughly researched with results published in peer-reviewed medical literature:

Clinical and Cost Outcomes of an Integrative Medicine IPA

J Manipulative Physiol Ther. 2004 Jun;27(5):336-47.
Richard L Sarnat, MD and James Winterstein, DC

Abstract 

Results: Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame.

Conclusion: In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone. While certainly promising, these initial results may not be consistent on a larger and more diverse population.

Link to abstract and publisher site for full study by clicking here.


This study is the 3-year update to the above research and confirmed the earlier findings:

Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update

J Manipulative Physiol Ther. 2007 May;30(4):263-9.
Richard L. Sarnat, MD, James Winterstein, DC, Jerrilyn A. Cambron, DC, PhD

Abstract 

Results: Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.

Conclusion: During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. Decreased utilization was uniformly achieved by all CAM-oriented PCPs, regardless of their licensure. The validity and generalizability of this observation are guarded given the lack of randomization, lack of statistical analysis possible, and potentially biased data in this population.

Click here to link to the abstract and the full study at the publisher site.

Attention policymakers: If you want to save money, consider chiropractors as PCPs.


More Key Articles About Chiropractic and the Alternative Medical Treatments of NSAID Drugs and Opiate Based Pain Medications

“Conservative management of mechanical neck disorders: a systematic review,” published in the Journal of Rheumatology in 2007 (v. 34, p. 1083-102), provides scientific evidence to support the fact that exercise combined with spinal manipulation demonstrates benefits in whiplash patients. This article was not a single study. Instead, it is a systematic review. The authors surveyed all of the literature including Medline and the Cochrane Reviews over a ten year period of time. They found 88 unique randomized controlled trials on various types of physical medicine and neck disorders. Two independent authors selected studies, abstracted data, assessed methodological quality from computerized databases, calculated relative risks, standardized mean differences when possible, and calculated pooled effect sizes. The conclusion was that “exercise combined with mobilization/manipulation . . .” is effective for chronic mechanical neck disorders.

“Treatment of Neck Pain: Noninvasive Interventions” puts an end to the debate about whether spinal manipulation has any benefit. The preeminent journal for both chiropractors and medical orthopedic surgeons is The Spine Journal. In 2008, the journal published the results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. This article "systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article. Those judged to have adequate internal validity were included in our best evidence synthesis.” The study concluded: “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain.”  Manual therapy is defined as including both mobilization and manipulation.

In regard to safety, the authors were impressed by the February 2008 Spine study on manipulation and stroke. The  authors noted: “These findings suggest that the increased risk of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection (in the prodromal stage) seeking care before their stroke. Thus, although cervical spine manipulation cannot be ruled out as a potential cause of some VBA strokes, any potential risk is very small.” (Spine, v. 33, n. 4S, pp. S123-S152, 2008).

Another huge landmark study, “Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews,” was published in a peer-reviewed medical journal in 2007. The following is the conclusion of these authors who were completely independent of those above: “The evidence reviewed here provides support for the contention that the manual therapies which induce joint mobility—manipulation and mobilization—are effective in the treatment of neck pain, especially chronic neck pain and neck pain due to whiplash injury, in those subjects who have been randomized to receive these therapies.” (Europa Medicophysica, 2007;43:91-118).

To develop a clinical practice guideline for acute and chronic low back pain, evidence was reviewed and then published for the American Pain Society/American College of Physicians in the prominent peer-reviewed Annals of Internal Medicine.The only non-pharmacological therapies found effective were as follows: "We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain. . . We found fair evidence that acupuncture, massage, yoga, and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine 147:492-504, 2007. This is strong validation for chiropractic care. Also found at this link -- click here.


The "Silent Epidemic" of NSAIDs

Why not just put all patients on NSAIDs? Here's why. From The New England Journal of Medicine, June 7, 1999: "It has been estimated conservatively that 16,500 NSAID-related deaths occur among patients with rheumatoid arthritis or osteoarthritis every year in the United States. This figure is similar to the number of deaths from the acquired immunodeficiency syndrome and considerably greater than the number of deaths from multiple myeloma, asthma, cervical cancer, or Hodgkin's disease. (Fig. 1). If deaths from gastrointestinal toxic effects of NSAIDS were tabulated separately in the National Vital Statistics reports, these effects would constitute the 15th most common cause of death in the United States. Yet these toxic effects, a largely "silent epidemic," with many physicians and patients unaware of the magnitude of the problem. Furthermore, the mortality statistics do not include deaths ascribed to the use of over-the counter NSAIDs. "Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs," M. Michael Wolfe, MD, David R. Lichtenstein, M.D., Gurkirpal Singh, MD, The New England Journal of Medicine, June 17, 1999, v. 340, n. 24.


Why not just put all patients on narcotic opiate-based pain-killers? Here's why.

Oct. 1, 2009 Report: Drugs More Lethal Than Car Crashes -- Government Agency Finds New Trend in Data From 16 States

(AP) In 16 states and counting, drugs now kill more people than auto accidents do, the government said Wednesday.

Experts said the startling shift reflects two opposite trends: Driving is becoming safer, and the legal and illegal use of powerful prescription painkillers is on the rise.

For decades, traffic accidents have been the biggest cause of injury-related death in the U.S., and they are still No. 1. But drug overdoses are pulling ahead in one state after another.

"People see a car accident as something that might happen to them," said Margaret Warner, an epidemiologist with the Centers for Disease Control and Prevention. But as for death from a drug overdose, "maybe they see it as something that's not going happen to them."

The drug-related death rate roughly doubled from the late 1990s to 2006, according to the most recent CDC data . . .

While cocaine and heroin continue to be significant killers, most of the increase is attributed to prescription opiates such as the painkillers methadone, Oxycontin and Vicodin . . . Read entire article by clicking here.

Prescriptions now biggest cause of fatal drug overdoses

By Liz Szabo, USA TODAY 10/02/09

Debra Jones didn't begin taking painkillers to get high.

Jones, 50, was trying to relieve chronic pain caused by rheumatoid arthritis.

Yet after taking the painkiller Percocet safely for 10 years, the stay-at-home mother of three became addicted after a friend suggested that crushing her pills could bring faster relief. It worked. The rush of medication also gave her more energy. Over time, she began to rely on that energy boost to get through the day. She began taking six or seven pills a day instead of the three to four a day as prescribed.

"I wasn't trying to abuse it," says Jones, from Holly Springs, N.C., who has since recovered from her battle with addiction. "But after 10 years, I couldn't help what it did to my body or my brain. It was hard to work without it."

Addiction to prescription painkillers — which kill thousands of Americans a year — has become a largely unrecognized epidemic, experts say. In fact, prescription drugs cause most of the more than 26,000 fatal overdoses each year, says Leonard Paulozzi of the Centers for Disease Control and Prevention.

The number of overdose deaths from opioid painkillers — opium-like drugs that include morphine and codeine — more than tripled from 1999 to 2006, to 13,800 deaths that year, according to CDC statistics released Wednesday.

In the past, most overdoses were due to illegal narcotics, such as heroin, with most deaths in big cities. Prescription painkillers have now surpassed heroin and cocaine, however, as the leading cause of fatal overdoses, Paulozzi says. And the rate of fatal overdoses is now about as high in rural areas — 7.8 deaths per 100,000 people — as in cities, where the rate is 7.9 deaths per 100,000 people, according to a paper he published last year in Pharmacoepidemiology and Drug Safety.

"The biggest and fastest-growing part of America's drug problem is prescription drug abuse," says Robert DuPont, a former White House drug czar and a former director of the National Institute on Drug Abuse. "The statistics are unmistakable."

Debra Jones, of Holy Springs, N.C., had become addicted to prescription Percocet, which she was taking for rheumatoid arthritis, and had to seek substance abuse treatment. She's been clean two years.

Click here to link to the full article on the USA Today webpage.


Is there scientific evidence to support chiropractic for nonmusculoskeletal conditions? Read here.

"Chiropractic Care for Nonmusculoskeletal Conditions: A Systematic Review with Implications for Whole Systems Research" concluded that evidence supports chiropractic care as providing benefits for asthma, cervicogenic vertigo and infantile colic. The review found evidence for chiropractic to be promising for care of children with otitis media and elderly with pneumonia. This study was published in the peer reviewed Journal of Alternative and Complementary Medicine, v.13, n.5, 2007, p. 491-512, Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW.

The National Board of Chiropractic Examiners has published a literature review regarding chiropractic treatment of asthma, infantile colic, fibromyalgia, premenstrual syndrome, back pain, neck pain and headache. NBCE is the national organization of all of the 50 state boards which license and regulate chiropractors. Click here to read the entire downloadable NBCE literature review in PDF format.

Chiropractic boycott must cease, Editorial by Alan M. Immerman, D.C. Phoenix Business Journal, August 20, 1999.