This section was compiled by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org
If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary. If you want information about a specific disease, you can access the Merck Manual. You can also search Pub Med for more abstracts on this, or any other health topic.
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Health Insights Today ~ FULL TEXT
In the current economic and political climate, one of the most important arguments to be made for any health care method is that it is cost-effective. As a result, researchers are redoubling their efforts to identify cost-effective approaches. This includes a growing number of studies addressing the cost-effectiveness of chiropractic services. Chiropractors and chiropractic students need to understand this information and to share it with others.
Cost-Effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions: A Systematic Review and Narrative Synthesis of Evidence From Randomized Controlled Trials
J Manipulative Physiol Ther. 2014 (Jun 27); [Epub ahead of print] ~ FULL TEXT
This review identified limited evidence indicating that manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy consisting of manipulation and mobilization techniques, and chiropractic manipulation), in addition to other treatments or alone, are more cost-effective than usual GP care (alone or with exercise), spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back pain and/or disability. Similarly, one study  demonstrated that spinal manipulation in addition to GP care was more cost-effective than GP care alone in reducing shoulder pain and related disability. The extra costs needed for 1-unit improvement in low back or shoulder pain/disability score or 1 QALY gained were lower than the WTP thresholds reported across the studies.
The Association of Complementary and Alternative Medicine Use
and Health Care Expenditures for Back and Neck Problems
Med Care. 2012 (Dec); 50 (12): 1029–1036
While health care conversations increasingly mention chiropractic care as a viable option for back and neck pain – and research increasingly supports its utility from a clinical standpoint – this nationwide study of complementary and alternative medicine (CAM)-related health care expenditures by 12,000-plus adults (ages 17 and older) with spinal conditions lends support to the suggestion that CAM in general, and chiropractic specifically, is also a cost-effective alternative to traditional medical care.
Spinal Manipulation Epidemiology:
Systematic Review of Cost Effectiveness Studies
J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 655–662
Six cost-effectiveness and cost-utility analysis were included. All included studies had a low risk of bias scoring =16/19 on the CHEC-List. SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to GP care, exercise and physiotherapy.
Value of Chiropractic Services at an On-site Health Center
Journal of Occupational and Environmental Medicine 2012 (Aug); 54 (8): 917–921
Although previous research has demonstrated the benefits of chiropractic care, to the best of our knowledge this study is the first to evaluate its impact when offered at an on-site health center. [6–10, 14–17] Given the convenience and quality of care provided by on-site health centers, it was hypothesized that on-site chiropractic care would be more beneficial than off-site clinic care. Despite some limitations that may have weakened the conclusions, the findings suggest on-site chiropractic services are associated with lower health care utilization of certain services and improved functional status of musculoskeletal conditions.
The Trials of Evidence:
Interpreting Research and the Case for Chiropractic
The Chiropractic Report ~ July 2011 ~ FULL TEXT
For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources – whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. ), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society ) or interdisciplinary (the European Back Pain Guidelines ).
A Hospital-Based Standardized Spine Care Pathway: Report of a Multidisciplinary, Evidence-Based Process
J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106 ~ FULL TEXT
A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as "excellent.
Cost-effectiveness of Guideline-endorsed Treatments for Low Back Pain: A Systematic Review
Eur Spine J. 2011 (Jul); 20 (7): 1024–1038
This systematic review of the cost-effectiveness of treatments endorsed in the APS-ACP guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, as were other methods usually within the chiropractor’s scope of practice (interdisciplinary rehabilitation, exercise, and acupuncture). For acute low back pain, this review found insufficient evidence for reaching a conclusion about the cost-effectiveness of spinal manipulation. It also found no evidence at all on the cost-effectiveness of medication for low back pain..
Functional Scores and Subjective Responses of Injured Workers With Back or Neck Pain Treated With Chiropractic Care in an Integrative Program: A Retrospective Analysis of 100 Cases
J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 765–771 ~ FULL TEXT
Injured workers with either an acute or subacute injury had significantly lower posttreatment FRI scores compared with individuals with a chronic injury. The FRI change scores were significantly greater in the acute group compared with either the subacute or chronic injured workers. Workers in all categories showed improved posttreatment tolerance for work-related activities and significantly lower posttreatment subjective pain scores.The study identified positive effects of chiropractic management included in integrative care when treating work-related neck or back pain. Improvement in both functional scores and subjective response was noted in all 3 time-based phases of patient status (acute, subacute, and chronic).
Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain
Improve the Value of Health Benefit Plans?
Mercer Health and Benefits LLC ~ October 12, 2009 ~ FULL TEXT
This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.
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): 263–269 ~ FULL TEXT
A new retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management, demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 83% pharmaceutical costs when compared with conventional medicine IPA performance. This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.
Cost-effectiveness of Medical and Chiropractic Care for Acute and Chronic Low Back Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 555–563 ~ FULL TEXT
Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients.
Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain. There are more articles like this in the Low Back Pain Page.
Cost Effectiveness of Physical Treatments for Back Pain in Primary Care
British Medical Journal 2004 (Dec 11); 329 (7479): 1381 ~ FULL TEXT
We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with "usual care" in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain.(1) Read more about this on the
UK BEAM Trial Page
The authors concluded: "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." You may also enjoy this recent press release and this glowing review on WebMD.
Chiropractic Care: Is It Substitution Care or Add-on Care in Corporate Medical Plans?
J Occup Environ Med 2004 (Aug); 46 (8): 847-855
An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. These results (of this file review) indicate that patients use chiropractic care as a direct substitution for medical care.
Clinical and Cost Outcomes of an Integrative Medicine IPA
J Manipulative Physiol Ther 2004 (Jun) ; 27 (5): 336–347 ~ FULL TEXT
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.
In the treatment of musculoskeletal disorders, despite the fact that most studies have not properly factored in such patient characteristics as severity and chronicity and lack the complete assessment of all direct costs and most indirect costs, the bulk of articles reviewed demonstrate lower costs for chiropractic. 
This pattern is consistently observed from the perspectives of workers' compensation studies,
 databases from insurers,
, or the analysis of a health economist employed by the provincial government of Ontario.
Other studies have suggested the opposite [that chiropractic services are more expensive than medical],
but these contain significant flaws which have been refuted.
The cost advantages for chiropractic for matched conditions appear to be so dramatic that Pran Manga, the aforementioned Canadian health economist, has concluded that doubling the utilization of chiropractic services from 10% to 20% may realize savings as much as $770 million in direct costs and $3.8 billion in indirect costs.  When iatrogenic effects [yet to be discussed] are factored in, the cost advantages of spinal manipulation as a treatment alternative become even more prominent. In one study, for instance, it was shown that for managing disc herniations, the cost of treatment failures following a medical course of treatment [chymopapain injections] averaged 300 British pounds per patient, while there were no such costs following spinal manipulation. , Imagine how failed back surgery might compare. Finally, in no cost studies to date have legal burdens been calculated, which one would expect should be heavily advantageous for chiropractic health management.
Chiropractic Treatment of Workers' Compensation Claimants
in the State of Texas
MGT of America, Austin, Texas ~ February 2003
In 2002, the Texas Chiropractic Association (TCA) commissioned an independent study to determine the use and effectiveness of chiropractic with regard to workers' compensation, the results of which were published in February 2003. According to the report, chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries. They found: Lower back and neck injuries accounted for 38 percent of all claims costs. Chiropractors treated about 30 percent of workers with lower back injuries, but were responsible for only 17.5 percent of the medical costs and 9.1 percent of the total costs. These findings were even more intertesting: The average claim for a worker with a low-back injury was $15,884. However, if a worker received at least 75 percent of his or her care from a chiropractor, the total cost per claimant decreased by nearly one-fourth to $12,202. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent, to $7,632.
Single-blind Randomised Controlled Trial of Chemonucleolysis and Manipulation in the Treatment of Symptomatic Lumbar Disc Herniation
Eur Spine J 2000 (Jun); 9 (3): 202–207
Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. In this study it was shown that for managing disc herniations, the cost of treatment failures following a medical course of treatment [chymopapain injections] averaged 300 British pounds per patient, while there were no such costs following spinal manipulation.
Economic Case for the Integration of Chiropractic Services into the Health Care System
J Manipulative Physiol Ther 2000 (Feb); 23 (2): 118-122 ~ FULL TEXT
For much of its history, chiropractic care has been both an alternative therapeutic paradigm and separate from or marginal to the mainstream health care system. Over the past decade, the situation has changed somewhat in that chiropractic care is gradually being integrated within a variety of health care delivery organizations. According to Triano et al,1 by the application of evidence-based health care and good business, there is a surge in cooperation and integration among chiropractors, allopathic physicians, allied health care providers, ancillary therapists, and respective support staff. There is, however, no quantification of the level of integration. Integration may also be more true of the United States than elsewhere. The overall position of chiropractic care as alternative and separate still predominates. This situation does not serve the interests of the chiropractic profession nor the public well. There is a persuasive economic case for a radical shift in the role of chiropractic care to one that may succinctly be described as alternative and mainstream. The chiropractic profession must preserve its identity and its unique therapeutic paradigm and continue to be seen as an alternative to other health care professions, especially medical doctors. However, it should also become mainstream and thus widely available and accessible to the public by being integrated into the wide variety of health care delivery organizations that collectively constitute the health care system.
Studies on Chiropractic 2000
National Board of Chiropractic Examiners
Chiropractic is now firmly rooted in the public consciousness as a primary agent of health care management. According to a 1990 study published in the New England Journal of Medicine, the number of visits to non-medical health care providers in 1990 totaled 425 million, 9.5% more than the total number of visits to all family physicians (Eisenberg et al.1993). A follow-up study determined that, in 1997, total visits to non-medical providers amounted to 629 million, exceeding the total projected visits to all primary care physicians by 63% (Eisenberg et al. 1998). Moreover, a 1998 study published in the New England Journal of Medicine reported chiropractic as the most used non-medical treatment (15.7%) (Astin 1998).
Costs and Recurrences of Chiropractic
and Medical Episodes of Low-back Care
J Manipulative Physiol Ther 1997 (Jan); 20 (1): 5–12
Total insurance payments within and across episodes were substantially greater for medically initiated episodes. Analysis of recurrent episodes as measures of patient outcomes indicated that chiropractic providers retain more patients for subsequent episodes, but that there is no significant difference in lapse time between episodes for chiropractic vs. medical providers. Chiropractic and medical patients were comparable on measures of severity; however, the chiropractic cohort included a greater proportion of chronic cases.
Chiropractic and Medical Costs of Low Back Care
Med Care 1996 (Mar); 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.
Comparing the Costs Between Provider Types of Episodes of Back Pain Care
SPINE (Phila Pa 1976) 1995 (Jan 15); 20 (2): 221–227
There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits. Chiropractors and general practitioners were the primary providers for 40% and 26% of episodes, respectively. Chiropractors had a significantly greater mean number of visits per episode (10.4) than did other practitioners. Orthopedic physicians and "other" physicians were significantly more costly on a per visit basis. Orthopedists had the highest mean total cost per episode, and general practitioners the lowest.
Further Analysis of Health Care Costs for Chiropractic and Medical Patients
J Manipulative Physiol Ther 1994 (Sep); 17 (7): 442–446
The analysis of well-insured patients in plans that do not restrict the chiropractic benefit strengthens results previously reported. In this study, therefore, the favorable cost patterns for chiropractic patients cannot be attributed to insurance restrictions limiting reimbursement for chiropractic services relative to other services. Because adjustments for patient characteristics systematically reduce the cost advantages of chiropractic patients as compared to mean differences derived from unadjusted data, the results also demonstrate that adjusted values should be used for meaningful comparisons between the two groups of patients.
A Comparison of Health Care Costs for Chiropractic and Medical Patients
J Manipulative Physiol Ther 1993 (Jun); 16 (5): 291–299
Nearly one-fourth of patients were treated by chiropractors. Patients receiving chiropractic care experienced significantly lower health care costs as represented by third party payments in the fee-for-service sector. Total cost differences on the order of $1,000 over the 2-yr period were found in the total sample of patients as well as in subsamples of patients with specific disorders. The lower costs are attributable mainly to lower inpatient utilization. The cost differences remain statistically significant after controlling for patient demographics and insurance plan characteristics.
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. This was an outcomes study funded by the Ontario Ministry of Health. The study was conducted by three health economists led by University of Ottawa Professor Pran Manga, Ph.D. The report of the study is commonly called the Manga Report. The Manga Report overwhelmingly supported the efficacy, safety, scientific validity, and cost-effectiveness of chiropractic for low-back pain. Additionally, it found that higher patient satisfaction levels were associated with chiropractic care than with medical treatment alternatives. On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP. It also found that many medical therapies are of questionable validity, or are clearly inadequate.
Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic
Management Within the Victorian WorkCare Scheme
Chiropractic Journal of Australia 1992 (Jun); 22 (2): 47–53
Comparisons of costs and outcomes were made between the two samples with the results being:
(i) a significantly lower number of claimants requiring compensation days when chiropractic management was chosen,
(ii) fewer compensation days taken by claimants who received chiropractic management,
(iii) a greater number of patients progressed to chronic status when medical management was chosen, and
(iv) a greater average payment per claim with medical management>.
A Comparison of the Cost of Chiropractors
Versus Alternative Medical Practitioners
Richmond, VA: Virginia Chiropractic Association, 1992
A 1992 study conducted by L.G. Schifrin, Ph.D., provided an economic assessment of mandated health insurance coverage for chiropractic treatment within the Commonwealth of Virginia. As reported by the College of William and Mary, and the Medical College of Virginia, the study indicated that chiropractic provides therapeutic benefits at economical costs. The report also recommended that chiropractic be a widely available form of health care. This paper is unavailable through PubMed or the Mantis database.
Disabling Low Back Oregon Workers' Compensation Claims
Part III: Diagnostic and Treatment Procedures and Associated Costs
J Manipulative Physiol Ther. 1991 (Jun); 14 (5): 287–297
Claimants in Oregon with disabling low back injuries attending chiropractors were found to have more treatments over a longer duration and at greater cost than claimants attending medical physicians with similar clinical presentations. These findings are attributed to: a) a higher proportion of chiropractic claimants than medical physician claimants with low back risk factors which may have adversely affected the course of recovery (chronic or recurrent low back conditions, obesity, extremity symptomatology, frequency of exacerbations); b) differences in age and gender of DC and MD claimants; c) the greater physician-patient contact hours characteristic of chiropractic practice; d) differences in therapeutic modalities employed; and e) the physician reimbursement permitted under Oregon workers' compensation law. The findings of this study emphasize the need for prospective studies of treatment outcome.
Disabling Low Back Oregon Workers' Compensation Claims
Part II: Time Loss
J Manipulative Physiol Ther 1991 (May); 14 (4): 231–239
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.
A Comparison of Chiropractic, Medical and Osteopathic Care
for Work-related Sprains and Strains
J Manipulative Physiol Ther 1989 (Oct); 12 (5): 335–344
For those who received care from DCs (n = 266), the mean number of compensated days lost from work was at least 2.3 days less than for those who were treated by MDs (n = 494; p less than 0.025) and at least 3.8 days less than for those who were treated by DOs (n = 102; p less than 0.025). Consequently, much less money in employment compensation was paid, on the average, to those who saw DCs.
An Analysis of Florida Workers' Compensation
Medical Claims for Back-related Injuries
Journal of the American Chiro Association 1988; 25 (7): 50–59
This study of 10,652 Florida Workers’ Compensation cases was conducted by Steve Wolk, Ph.D. , and reported by the Foundation for Chiropractic Education and Research. It was concluded that “a claimant with a back-related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled, or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors.”
The analysis focused on the cost of treatment, frequency of compensable injuries (an injury which disables an individual for more than seven days, resulting in wage compensation benefits), and frequency of hospitalization for workers' compensation claim patient (end of reference).
End Medical Mis-Management of Musculoskeletal Complaints
Q. Are medical doctors well trained to diagnose or treat musculoskeletal complaints?
A. Read the unsettling answer in this series of articles
Educational Deficiencies in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 2002 (Apr); 84–A (4): 604–608
According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate. NOTE: This is a follow-up article to the study cited below, which
demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. Ask yourself: What would the headlines scream if, after 4 years, chiropractors had failed to improve their skills in musculoskeletal assessment and management? Why is medicine is shown more slack?
The Adequacy of Medical School Education in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 1998 (Oct); 80-A (10): 1421–1427
This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that "we therefore believe that medical school preparation in musculoskeletal medicine is inadequate" and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints.
Educating Medical Students About Musculoskeletal Problems: Are Community Needs Reflected in the Curricula of Canadian Medical Schools?
Journal of Bone and Joint Surgery 2001 (Sept); 83-A (9): 1317–1320
Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. (So they conclude:) There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.
A Comparison of Chiropractic Student Knowledge Versus Medical Residents
Proceedings of the World Federation of Chiropractic Congress 2001 Pgs. 255
A previously published knowledge questionnaire designed by chief orthopedic residents was given to a Chiropractic student group for comparison to the results of the medical resident group. Based on the marking scale determined by the chief residents, the Chiropractic group (n = 51) showed statistically significant higher average grade than the orthopedic residents. Expressed in other terms, 70% of chiropractic students passed the knowledge questionnaire, compared to an 80% failure rate for the orthopedic residents.
Musculoskeletal Knowledge: How Do You Stack Up?
Physician and Sportsmedicine 2002; 30 (8) August
One of every 4 or 5 primary care visits is for a musculoskeletal problem. Yet undergraduate and graduate training for this burden of illness continues to constitute typically less than 5% of the medical curriculum. This is an area of clear concern, but also one in which sports medicine practitioners can assume leadership.
Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov); 32 (11)
It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment. This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.1 While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.
Adequacy of Education in Musculoskeletal Medicine
J Bone Joint Surg Am 2005 (Feb);87 (2): 310–314
In this study, 334 medical students, residents and staff physicians, specializing in various fields of medicine, were asked to take a basic cognitive examination consisting of 25 short-answer questions - the same type of test administered in the original JBJS 1998 study. The average score among medical doctors, students and residents who took the exam in 2005 was 2.7 points lower than those who took the exam in 1998. Just over half of the staff physicians (52%) scored a passing grade or higher on the 2005 exam. Only 21% of the residents registered a passing grade, and only 5% of the medical students passed the exam. Overall, Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination.
More Evidence of Educational Inadequacies in Musculoskeletal Medicine
Clin Orthop Relat Res 2005 (Aug); (437): 251–259
A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.
• Manipulation, with or without exercise, improved symptoms more than medical care did after both 3 and 12 months
• The authors concluded:
“We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice.”
Additional Cost-Effectiveness Studies
Thanks to the NBCE for the use of this information!
The National Board of Chiropractic Examiners
published reports based on a four-year study of chiropractic. These
reports focused on three surveys including full-time,
licensed U.S., Canadian and registered Australian and New Zealand chiropractic
practitioners. The surveys and their resulting reports are titled
Job Analysis of Chiropractic.
Following publication of the Job Analysis of Chiropractic,
the NBCE began to receive requests for permission to reproduce certain
portions of the reports. In response to those requests, the NBCE
has condensed relevant portions and reprinted them in this brochure.
In recent years, numerous independent researchers
and various government agencies have conducted studies which focus
on the efficacy, appropriateness and cost-effectiveness of chiropractic
treatment. Several of these important studies are listed below.
U.S. GOVERNMENT AGENCY REPORT
A 1994 study published by the U.S. Agency for Health Care Policy and
Research (AHCPR) and the U.S. Department of Health and Human Services
endorses spinal manipulation for acute low back pain in adults in its Clinical
Practice Guideline # 14. An independent multidisciplinary panel of
private-sector clinicians and other experts convened and developed specific
statements on appropriate health care of acute low back problems in adults.
One statement cited, relief of discomfort (low back pain) can be
accomplished most safely with spinal manipulation, and/or nonprescription
A major study to assess the most appropriate use of available health
care resources was reported in 1993. This was an outcomes study funded
by the Ontario Ministry of Health and conducted in hopes of sharing information
about ways to reduce the incidence of work-related injuries and to address
cost-effective ways to rehabilitate disabled and injured workers. The study
was conducted by three health economists led by University of Ottawa Professor
Pran Manga, Ph.D. The report of the study is commonly called the
Manga Report. The Manga Report overwhelmingly supported the efficacy,
safety, scientific validity, and cost-effectiveness of chiropractic for
low-back pain. Additionally, it found that higher patient satisfaction
levels were associated with chiropractic care than with medical treatment
alternatives. “Evidence from Canada and other countries suggests
potential savings of hundreds of millions annually,” the Manga Report
states. “The literature clearly and consistently shows that the major savings
from chiropractic management come from fewer and lower costs of auxiliary
services, fewer hospitalizations, and a highly significant reduction in
chronic problems, as well as in levels and duration of disability.”
A four-phase study conducted in the early 1990s by RAND, one of America’s
most prestigious centers for research in public policy, science and technology,
explored many indications of low-back pain. In the RAND studies,
an expert panel of researchers, including medical doctors and doctors of
chiropractic, found that:
chiropractors deliver a substantial amount of health care to the U.S. population.
spinal manipulation is of benefit to some patients with acute low-back pain.
The RAND reports marked the first time that representatives of the medical community went on record stating that spinal manipulation is an appropriate treatment for certain low-back pain conditions.
THE NEW ZEALAND COMMISSION REPORT
A particularly significant study of chiropractic was conducted between
1978-1980 by the New Zealand Commission of Inquiry. In its 377-page
report to the House of Representatives, the Commission called its study
“probably the most comprehensive and detailed independent examination of
chiropractic ever undertaken in any country.” The Commission entered
the inquiry with “the general impression ... shared by many in the community:
that chiropractic was an unscientific cult, not to be compared with orthodox
medical or paramedical services.” By the end of the inquiry,
the commission reported itself “irresistibly and with complete unanimity
drawn to the conclusion that modern chiropractic is a soundly-based and
valuable branch of health care in a specialized area...” Conclusions
of the Commission’s report, based on investigations in New Zealand,
the U.S., Canada, the United Kingdom, and Australia, stated:
Spinal manual therapy in the hands of a registered chiropractor is safe.
Spinal manual therapy can be effective in relieving musculo-skeletal symptoms such as back pain, and other symptoms known to respond to such therapy, such as migraine.
Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy.
In the public interest and in the interests of patients, there must be no impediment to full professional cooperation between chiropractors and medical practitioners.
STATE OF TEXAS WORKERS' COMPENSATION STUDY OF 2003
In 2002, the Texas Chiropractic Association (TCA) commissioned an independent study to determine the use and effectiveness of chiropractic with regard to workers' compensation, the results of which were published in February. According to the report, Chiropractic Treatment of Workers' Compensation Claimants in the State of Texas, chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries. They found:
Lower back and neck injuries accounted for 38 percent of all claims costs. Chiropractors treated about 30 percent of workers with lower back injuries, but were responsible for only 17.5 percent of the medical costs and 9.1 percent of the total costs. These findings were even more intertesting: The average claim for a worker with a low-back injury was $15,884. However, if a worker received at least 75 percent of his or her care from a chiropractor, the total cost per claimant decreased by nearly one-fourth to $12,202. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent, to $7,632.
FLORIDA WORKERS’ COMPENSATION STUDY
A 1988 study of 10,652 Florida workers’ compensation cases was conducted
by Steve Wolk, Ph.D. , and reported by the Foundation for Chiropractic
Education and Research. It was concluded that “a claimant with a back-related
injury, when initially treated by a chiropractor versus a medical doctor,
is less likely to become temporarily disabled, or if disabled, remains
disabled for a shorter period of time; and claimants treated by medical
doctors were hospitalized at a much higher rate than claimants treated
by chiropractors.” Some of the study results were:
51.3 percent shorter temporary total disability duration with chiropractic care
lower treatment cost by 58.8 percent ($558 vs. $1,100 per case) in the chiropractic group, and
20.3 percent hospitalization rate in the chiropractic care group vs. 52.2 percent rate in the medical care group
WASHINGTON HMO STUDY
In 1989, a survey administered by Daniel C. Cherkin, Ph.D., and Frederick A. MacCornack, Ph.D., concluded that
patients receiving care from health maintenance organizations (HMOs) within the state of Washington were three times as likely to report satisfaction with care from chiropractors as they were with care from other physicians. The patients were also more likely to believe that their chiropractor was concerned about them.
This Compensation Board study found the total treatment costs for back-related injuries cost an average of $775.30 per case when treated by a doctor of chiropractic. When injured workers received standard medical treatment as opposed to chiropractic treatment, the average cost per case was $1,665.43. They also found the mean compensation cost paid out by the Utah Worker's Compensation Board for patients treated by medical doctors was $668.39, while the mean compensation cost paid for patients treated by chiropractic doctors was only $68.38.
A 1992 article in the Journal of Family Practice reported a study by DC Cherkin, Ph.D., which compared patients of family physicians and of chiropractors. The article stated “the number of days of disability for patients seen by family physicians was significantly higher (mean 39.7) than for patients managed by chiropractors (mean 10.8).” A related editorial in the same issue referred to risks of complications from lumbar manipulation as being “very low.”
OREGON WORKERS’ COMPENSATION STUDY
A 1991 report on a workers’ compensation study conducted in Oregon
by Joanne Nyiendo, Ph.D., concluded that the median time loss days (per
case) for comparable injuries was 9.0 for patients receiving treatment
by a doctor of chiropractic and 11.5 for treatment by a medical doctor.
STANO COST COMPARISON STUDY
Miron Stano, PhD, a health care economist at Oakland University, conducted a study comparing the health-care costs for chiropractic and medical patients with neuromusculoskeletal conditions. The database he used came from the records of
MEDSTAT Systems, Inc., a health benefits management consulting firm which processes insurance claims for many of the country's largest corporations. This June 1993 Journal of Manipulative and Physiological Therapeutics study involved 395,641 patients, drawn from statistical information on more than two million beneficiaries.
Results over a two-year period showed that patients who received chiropractic care incurred significantly lower health care costs than did patients treated solely by medical or osteopathic physicians.
DISTRIBUTION OF TOTAL COST PER CASE FOR SELECTED ICD-9 CODES (MEAN VALUES)
TOTAL COST (MEDICAL)
TOTAL COST (CHIROPRACTIC)
Total Cost of Selected Cases
Average Cost Per Case
Also of interest, for those patients receiving both medical and chiropractic care, the Stano/MEDSTAT results revealed:
31 percent lower hospital admissions rates;
43 percent lower inpatient payments; and
23 percent lower total health care costs.
SASKATCHEWAN CLINICAL RESEARCH
Following a 1993 study, researchers J. David Cassidy, D.C., Haymo Thiel,
D.C., M.S., and W. Kirkaldy-Willis, M.D., of the Back Pain Clinic at the
Royal University Hospital in Saskatchewan concluded that “the treatment
of lumbar intervertebral disk herniation by side posture manipulation is
both safe and effective.”
UNIVERSITY OF SASKATCHEWAN STUDY OF 1985
In 1985 the University of Saskatchewan conducted a study of 283 patients “who had not responded to previous conservative or operative treatment” and who were initially classified as totally disabled. The study revealed that
“81% ... became symptom free or achieved a state of mild intermittent pain with no work restrictions” after daily spinal manipulations were administered.
WIGHT STUDY ON RECURRING HEADACHES
A 1978 study conducted by J.S. Wight, D.C. , and reported in the ACA
Journal of Chiropractic, indicated that 74.6% of patients with recurring
headaches, including migraines, were either cured or experienced reduced
headache symptomatology after receiving chiropractic manipulation.
1991 GALLUP POLL
A 1991 demographic poll conducted by the Gallup Organization revealed that 90% of chiropractic patients felt their treatment was effective; more than 80% were satisfied with that treatment; and nearly 73% felt most of their expectations had been met during their chiropractic visits.
A study conducted by T.W. Meade, a medical doctor, and reported in the
June 2, 1990, British Medical Journal concluded after two years of patient monitoring, “for patients with low-back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management.” More importantly, this article contradicts other articles which maintained that spinal adjusting (manipulation) was only effective for "acute" low back pain
. This article found: The benefit is seen mainly in those with chronic or severe pain . It also suggested that “introducing chiropractic into NHS practice should be considered.”
A 1992 review of data from over 2,000,000 users of chiropractic care in the U.S., reported in the Journal of American Health Policy, stated that
“chiropractic users tend to have substantially lower total health care costs,”
“chiropractic care reduces the use of both physician and hospital care.”
1985 UNIVERSITY OF SASKATCHEWAN STUDY
In 1985 the University of Saskatchewan conducted a study of 283 patients
“who had not responded to previous conservative or operative treatment”
and who were initially classified as totally disabled. The study revealed
that “81% ... became symptom free or achieved a state of mild intermittent
pain with no work restrictions” after daily spinal manipulations were administered.
Further validation of chiropractic care evolved from an antitrust suit
which was filed by four members of the chiropractic profession against
the American Medical Association (AMA) and a number of other health care
organizations in the U.S. (Wilk et al v. AMA et al, 1990). Following
11 years of litigation, a federal appellate court judge upheld a ruling
by U.S. District Court Judge Susan Getzendanner that the AMA had engaged
in a “lengthy, systematic, successful and unlawful boycott” designed to
restrict cooperation between MDs and chiropractors in order to eliminate
the profession of chiropractic as a competitor in the U.S. health care
system. Judge Getzendanner rejected the AMA’s patient care defense,
and cited scientific studies which implied that “chiropractic care was
twice as effective as medical care in relieving many painful conditions
of the neck and back as well as related musculo-skeletal problems."
Since the court’s findings and conclusions were released, an increasing
number of medical doctors, hospitals, and health care organizations in
the U.S. have begun to include the services of chiropractors.
In order to become a licensed doctor of chiropractic, an individual
must meet stringent testing, academic and professional requirements.
Currently, an individual must complete the four major steps shown below
in order to become a chiropractic practitioner:
Government inquiries (some of which are described in this brochure),
as well as independent investigations by medical practitioners, have affirmed
that today’s chiropractic academic training is of equivalent standard to
medical training in all pre-clinical subjects. High standards in
chiropractic education are maintained by the Council on Chiropractic Education
(CCE) and its Commission on Accreditation, as recognized by the U.S.
Department of Education. Some Chiropractic colleges require a Bachelor's
degree before enrollment. A doctor of chiropractic’s training generally
requires a minimum of six years of college study (two years of which are
undergraduate course work) and an internship prior to entering practice.
Postdoctoral training in a variety of clinical disciplines and specialties
is also available through accredited colleges and specialty councils.
Chiropractic is one of many occupations which are regulated by state
licensing agencies. The requirements for chiropractic licensure vary from
state to state (and country to country). Some states require a Bachelor's
degree as a prerequisite for licensure. To assist the various regulatory
agencies in assessing candidates for licensure, the National Board administers
examinations to individuals currently in the chiropractic educational system
or who have completed a chiropractic educational program. The National
Board also offers an examination designed for previously licensed individuals.
A candidate for chiropractic licensure may request that transcripts
of scores from National Board examinations be forwarded to licensing agencies
which assess eligibility for licensure. Scores from National Board
examinations are made available to licensing agencies throughout the U.S.
and in some foreign countries including Canada, the United Kingdom, France