Welcome to the Initial Provider/First Contact section @ Chiro.Org   This section contains
a collection of articles reviewing how chiropractic can and does contribute.

Initial Provider/First Contact and Chiropractic

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:

Jump to: Reference Materials Recent Studies Search INITIAL PROVIDER


Patient Satisfaction Pediatric Section Safety of Chiropractic

Exercise + Chiropractic Chiropractic Rehab Integrated Care

Headache Page Care For Veterans Disc Herniation

Chronic Neck Pain Low Back Pain Whiplash Section

Conditions That Respond Alternative Medicine Approaches to Disease


Reference Materials

Cost-Effectiveness of Chiropractic
A Chiro.Org article collection

Take a close look at the 3 Cost-Effectiveness Triumvirate articles, as they detail how other studies have under-valued chiropractic care, by simply ignoring other medical and social costs, like extended unemoployment, drug costs and side-effects, and referred care patterns. They are a real eye-opener.

Chronic Neck Pain and Chiropractic
A Chiro.Org article collection

This section contains articles going back to the early 90s, and also provides an impressive Reference Materials section.

Low Back Pain and Chiropractic
A Chiro.Org article collection

This section contains articles going back to 1985, and also provides some helpful sub-sections on Patient Expectations of Relief, the Trajectories of Low Back Pain and a detailed section on What is Usual (medical) Care? .

Headache and Chiropractic
A Chiro.Org article collection

This section contains articles going back to 1988, and also provides some helpful sub-sections on the sub-types of headaches, including Cervicogenic, Chronic Tension, and Migraine Headache.

Chiropractic Care For Veterans
A Chiro.Org article collection

Enjoy this collection of articles by DCs who treat our Vets, going back to 2002. It ALSO contains a section with the collected Congressional Acts and Veterans Affairs Documents as a reference.

Workers' Compensation and Chiropractic
A Chiro.Org article collection

Studies going back to the 1980s reveal that chiropractic care gets workers back to work faster and cheaper than standard medical care. Drop by and enjoy this new topical collection.


Recent Studies

Initial Choice of Spinal Manipulation Reduces Escalation of Care
for Chronic Low Back Pain Among Older Medicare Beneficiaries

Spine (Phila Pa 1976) 2021 (May 11) [EPUB] ~ FULL TEXT

SMT was associated with lower rates of escalation of care as compared to Opioid Analgesic Therapy (OAT).   Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy. Level of Evidence: 3.

Association of Initial Provider Type on Opioid Fills
for Individuals With Neck Pain

Archives of Phys Med and Rehabilitation 2020 (Aug);   101 (8):   1407–1413 ~ FULL TEXT

Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%–91% less likely to fill an opioid prescription in the first 30 days, and between 41%–87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47–3.69; P<.001).

Experiences With Chiropractic Care for Patients with
Low Back or Neck Pain

J Patient Exp 2020 (Jun);   7 (3):   357–364 ~ FULL TEXT

We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points).   The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.

Primary Care for Low Back Pain:
We Don't Know the Half of It

Pain. 2020 (Apr);   161 (4):   663–665 ~ FULL TEXT

In a new systematic review, Kamper et al. [What is Usual Care for Low Back Pain?] (See it directly below this article) tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, [17] and there is good evidence for what constitutes best first-contact treatment. [6] The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit). [2, 3, 16]
Refer to our extensive Low Back Pain collection, titled: What is Usual Care?

What is Usual Care for Low Back Pain? A Systematic Review
of Health Care Provided to Patients with Low Back Pain
in Family Practice and Emergency Departments

Pain. 2020 (Apr);   161 (4):   694–702 ~ FULL TEXT

International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis.   Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs.
Refer to our extensive Low Back Pain collection, titled: What is Usual Care?

Treatment of Patients with Low Back Pain: A Comparison
of Physical Therapy and Chiropractic Manipulation

Healthcare (Basel) 2020 (Feb 24);   8 (1):   44 ~ FULL TEXT

This study analyzed these two strategies and showed that in the short term, chiropractic care is a more cost-effective alternative compared to PT for the treatment of acute low back pain. Chiropractic resulted in a lower cost ($48.56) and higher DALY (0.0043) than the PT over a one-month treatment period and five months follow-up. However, the marginal cost-effectiveness of chiropractic over PT suggests that both treatments were quite similar. Such findings are in line with the earlier studies, which found that the effectiveness and total costs of chiropractic and PT as primary treatments were similar to each other right after treatment and after 6 months follow-up. [3, 22, 32]

The Features and Burden of Headaches Within a Chiropractic
Clinical Population: A Cross-sectional Analysis

Complementary Therapies in Medicine 2020 (Jan);   48:   102276 ~ FULL TEXT

One in four participants (n = 57; 25.4%) experienced chronic headaches and 42.0% (n = 88) experienced severe headache pain. In terms of headache features, 20.5% (n = 46) and 16.5% (n = 37) of participants had discrete features of migraine and tension-type headache, respectively, while 33.0% (n = 74) had features of more than one headache type. 'Severe' levels of headache impact were most often reported in those with features of mixed headache (n = 47; 65.3%) and migraine (n = 29; 61.7%). Patients who were satisfied or very satisfied with headache management by a chiropractor were those who were seeking help with headache-related stress or to be more in control of their headaches. Many with headache who consult chiropractors have features of recurrent headaches and experience increased levels of headache disability. These findings may be important to other headache-related healthcare providers and policymakers in their endeavours to provide coordinated, safe and effective care for those with headaches.

Observational Retrospective Study of the Association of
Initial Healthcare Provider for New-onset Low Back Pain
with Early and Long-term Opioid Use

BMJ Open. 2019 (Sep 20);   9 (9):   e028633 ~ FULL TEXT

Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Chiropractic Integration Within a Community Health Centre:
A Cost Description and Partial Analysis of Cost-utility
from the Perspective of the Institution

J Can Chiropr Assoc. 2019 (Aug);   63 (2):   64-79 ~ FULL TEXT

This study evaluated the cost-utility of chiropractic integration for low back pain services within a primary care CHC setting from the perspective of the healthcare institution. Among the subjects followed in this study, the addition of chiropractic care to usual medical care was associated with improved outcomes at a reasonable cost. These outcomes, along with the potential cost savings of such integration, may have important implications for healthcare institutions and their patients, as well as for policy decision-makers and other health stakeholders. Future comparative cost and effectiveness studies with control of confounding are nevertheless needed to evaluate the impact of chiropractic care with or without usual medical care in these settings.

Care for Low Back Pain: Can Health Systems Deliver?
Bulletin of the World Health Organization 2019 (Jun 1);   97 (6):   423–433 ~ FULL TEXT

Delivery of guideline-concordant care for low back pain requires system-wide changes. Strong governance at each level of the health system will be key to redefining how society views and manages low back pain. Health systems should prioritize policies that: empower clinicians and consumers to make well-informed choices; encourage clinicians to deliver the right care to those who need it most; provide financial support to evidence-based non-pharmacological treatment; and regulate the influence of those with vested interests in the current situation. Small adjustments to health policy will not work in isolation. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change. Addressing system-level barriers to guideline-based care could be cost-neutral; every year health systems waste billions of dollars on unnecessary tests and treatments for low back pain. Although disinvestment is difficult, redistributing funds to support guideline-concordant care is a promising way forward. Because current approaches to treatment often lack formal evidence, we strongly encourage careful evaluation of any new approach to funding or service delivery.

Group and Individual-level Change on Health-related Quality of Life
in Chiropractic Patients With Chronic Low Back or Neck Pain

Spine (Phila Pa 1976) 2019 (May 1);   44 (9):   647–651 ~ FULL TEXT

The results of this study contribute to the literature by providing evidence that chiropractic care is associated with improvements in functioning and well-being among individuals with chronic low back or neck pain. The study findings provide empirical verification of why some chronic pain patients utilize chiropractic care on a regular basis. It supports the use of chiropractic care as one option for improving functioning and well-being of patients with chronic low back pain or neck pain. While we are unable to infer the underlying mechanism for the observed improvements in patients, spinal manipulation is designed to relieve pain and improve physical functioning. Studies of the biomechanics indicate that spinal manipulation produces reflex responses and movements of vertebral bodies in the para-physiologic zone. [27]

Self-reported Use of Family Physician, Chiropractor and Physiotherapy
Services Among Adult Canadians with Chronic Back Disorders:
An Observational Study

BMC Health Serv Res 2018 (Dec 17);   18 (1):   970 ~ FULL TEXT

This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations. The identified gaps in access to care among certain population groups demonstrates that there is not equitable access to care among Canadians with CBD. Enhancing access to potentially beneficial non-physician services for people with CBD requires rethinking the way front-line back care is delivered in Canada, including pressure on insurers and policy makers to cover and enable greater access to non-pharmacological management treatment options that have demonstrated value. [34, 40]

Cost-effectiveness of Spinal Manipulation, Exercise, and Self-management for
Spinal Pain Using an Individual Participant Data Meta-analysis Approach:
A Study Protocol

Chiropractic & Manual Therapies 2018 (Nov 13);   26:   46 ~ FULL TEXT

Combined analyses of economic data are rarely possible due to differences in resource utilization outcomes, costs and healthcare settings. [56, 57] Additionally, individual clinical trials rarely include a sufficient number of participants to detect important differences in economic outcomes. This project represents a unique opportunity to potentially combine clinical and economic data collected in eight randomized clinical trials using an IPDMA approach. This will provide more precise estimates of the cost-effectiveness of spinal manipulation, exercise therapy, and self-management compared to analysis of the individual trials. Further, an IPDMA approach has many advantages over traditional meta-analysis including the ability to conduct standardized within-study analyses, account for missing data at the individual level, and investigate potential sub-group effects at the participant level which may account for heterogeneity in estimates across studies. [52]

Long-term Relief from Tension-type Headache and Major Depression
Following Chiropractic Treatment

J Family Med Prim Care 2018 (May);   7 (3):   629–631 ~ FULL TEXT

We report the case of a 44-year-old school teacher who experienced long-term relief from tension-type headache (TTH) and major depression following chiropractic treatment. It is well recognized that psychiatric comorbidity and suicide risk are commonly found in patients with painful physical symptoms such as chronic headache, backache, or joint pain. Recent studies indicated that autonomic dysfunction plays a role in the pathogenesis of TTHs and depressive disorders. The autonomic nervous system is mainly controlled by reflex centers located in the spinal cord, brain stem, and hypothalamus. This report highlights the rewarding outcomes from spinal adjustment in certain neuropsychiatric disorders. Long-term results of chiropractic adjustment in this particular case were very favorable. Further studies with larger groups are warranted to better clarify the role of chiropractic.

Primary Care Management of Non-specific Low Back Pain:
Key Messages from Recent Clinical Guidelines

Medical J Australia 2018 (Apr 2);   208 (6):   272–275 ~ FULL TEXT

Changes in management as a result of the guidelines:

  • emphasising simple first line care with early follow-up;

  • encouraging non-pharmacological treatments over pharmacological treatments; and

  • recommending against the use of surgery, injections and denervation procedures.

Influence of Initial Provider on Health Care Utilization
in Patients Seeking Care for Neck Pain

Mayo Clin Proc Innov Qual Outcomes. 2017 (Oct 19);   1 (3):   226–233 ~ FULL TEXT

These findings support that initiating care with a nonpharmacological provider for a new episode of neck pain may present an opportunity to decrease opioid exposure (DC and PT) and advanced imaging and injections (DC only). Although these findings need confirmation in a better controlled study, our results suggest that adopting such a strategy aligns well with recent CDC and ACP recommendations and has the potential to decrease the management burden of neck pain by PCPs. Future research is needed to examine the association of patient-centered outcomes and health care utilization and to explore whether seeking care from a nonpharmacological provider is also associated with cost savings in addition to decreased health care utilization.

Association Between the Type of First Healthcare Provider and
the Duration of Financial Compensation for Occupational Back Pain

Journal of Occupational Rehabilitation 2017 (Sep);   27 (3):   382-392 ~ FULL TEXT

The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.
Refer to our extensive collection on: Workers' Compensation

Complementary and Integrative Medicine in the Management of Headache
British Medical Journal 2017 (May 16);   357:   j1805 ~ FULL TEXT

Headaches, including primary headaches such as migraine and tension-type headache, are a common clinical problem. Complementary and integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM), uses evidence informed modalities to assist in the health and healing of patients. CIM commonly includes the use of nutrition, movement practices, manual therapy, traditional Chinese medicine, and mind-body strategies. This review summarizes the literature on the use of CIM for primary headache and is based on five meta-analyses, seven systematic reviews, and 34 randomized controlled trials (RCTs).

Chiropractic Spinal Manipulative Therapy For Migraine: A Three-Armed,
Single-Blinded, Placebo, Randomized Controlled Trial

European Journal of Neurology 2017 (Jan);   24 (1):   143–153 ~ FULL TEXT

The blinding was strongly sustained throughout the RCT, adverse events (AEs) were few and mild, and the effect in the chiropractic spinal manipulative therapy (CSMT) and placebo group was probably a placebo response. Because some migraineurs do not tolerate medication because of AEs or co-morbid disorders, CSMT might be considered in situations where other therapeutic options are ineffective or poorly tolerated.

The Cost-Effectiveness Triumvirate

Variations in Patterns of Utilization and Charges for the Care of
Headache in North Carolina, 2000-2009:
A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   229-239 ~ FULL TEXT

Overall utilization and average charges for the treatment of headache increased considerably from 2000 to 2005 and then decreased in each subsequent year. Policy changes that took place between 2005 and 2007 may have affected utilization rates of certain providers and their associated charges. MD care accounted for the majority of total allowed charges throughout the decade. In general, patterns of care involving multiple providers and referral care incurred the largest charges, whereas patterns of care involving single or nonreferral providers incurred the least charges. MD-only, DC-only, and MD-DC care were the least expensive patterns of headache care; however, risk-adjusted charges (available 2006-2009) were significantly lower for DC-only care compared with MD-only care.

Variations in Patterns of Utilization and Charges for the Care of
Neck Pain in North Carolina, 2000 to 2009:
A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   240-251 ~ FULL TEXT

Increases in utilization and charges were the highest among patterns involving MDs, PTs and referral providers.   These findings are consistent with previous studies showing that medical specialty, diagnostic imaging, and invasive procedures (eg, spine injections, surgery) [17, 19, 20, 21] are significant drivers of increasing spine care costs.   When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population.   This is an opportunity to view costs laterally versus a confined, vertical analysis.

Variations in Patterns of Utilization and Charges for the Care of
Low Back Pain in North Carolina, 2000 to 2009:
A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   252-262 ~ FULL TEXT

A major strength of the study was the large amount of low back pain claims made available to us for analysis. The data were from 3,159,362 claims generated by approximately 66,0000 persons over the 2000-2009 decade in North Carolina, in several different pathways of healthcare services. This study and the series of papers it has generated on the treatment of low back pain, neck pain [25] and headache, [26] provides unique economic examination for healthcare policy makers and legislators.   When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population.   This is an opportunity to view costs laterally versus a confined, vertical analysis.

Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic
and Opioid Use in Younger Medicare Beneficiaries

J Manipulative Physiol Ther. 2016 (May);   39 (4):   263–266 ~ FULL TEXT

In this exploratory analysis, we found a strong inverse correlation between the per-capita supply of DCs and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Further, we found a strong inverse correlation between the per-capita spending on CMT and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Based upon our findings, we suggest that Medicare consider promoting a trial of CMT prior to use of conventional medical care for patients with neck or back pain. The rationale for use of CMT prior to medical care is that concurrent medical care might result in opioid prescriptions; however, further study that examines opioid use when CMT and conventional medical care are concurrently provided is warranted.

Importance of the Type of Provider Seen to Begin Health Care for
a New Episode Low Back Pain: Associations with
Future Utilization and Costs

J Eval Clin Pract. 2016 (Apr);   22 (2):   247–252 ~ FULL TEXT

The RESULTS portion of this Abstract only partially discusses the findings, comparing 3 different professions' treatment, costs, and outcomes for low back pain.   In it they only mention the costs associated with medical management, while in reviewing chiropractic care vs. physical thereapy portions, they choose to emphasize:

  • Entry in chiropractic was associated with an increased episode of care duration
  • Entry in physical therapy no patient entering in physical therapy had surgery.

That *seems* to suggest that physical therapy *may* entail less expense, or shorter durations of care, or that chiropractic patients are more likely to end up with surgery.   None of that is true.   Their own Table 2 plainly reveals that chiropractic care was the least expensive form of care provided to the 3 groups.

The Association Between Use of Chiropractic Care and Costs of Care
Among Older Medicare Patients With Chronic Low Back Pain
and Multiple Comorbidities

J Manipulative Physiol Ther. 2016 (Feb);   39 (2):   63–75 ~ FULL TEXT

After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided.

First-Contact Care With a Medical vs Chiropractic Provider After
Consultation with a Swiss Telemedicine Provider: Comparison
of Outcomes, Patient Satisfaction, and Health Care Costs
in Spinal, Hip, and Shoulder Pain Patients

J Manipulative Physiol Ther. 2015 (Sep);   38 (7):   477–483 ~ FULL TEXT

JMPT's Editor-in-Chief Claire Johnson, DC, MEd, emphasized the importance of the latest findings:
“Comparative studies – in other words, research that compares the outcomes between two different providers or modalities – are rare for chiropractic care,” she said.   “Thus, this study by Houweling, et al., is especially important if payers and policy-makers are to better understand the 'triple aim' as it relates to chiropractic. Specifically, this study helps us better understand what type of care provides better patient satisfaction, is more cost effective, and improves population health.”

Regional Supply of Chiropractic Care and Visits to Primary Care
Physicians for Back and Neck Pain

J Am Board Fam Med. 2015 (Jul);   28 (4):   481–490 ~ FULL TEXT

Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11–14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services. When extrapolated to the nation (based on our predictions from our adjusted model), we estimate that chiropractic care is associated with a reduction of 0.37 million visits to PCPs for back and/or neck pain at a total cost of $83.5 million (Table 3).

Chiropractic Use in the Medicare Population: Prevalence, Patterns,
and Associations With 1-Year Changes in Health and Satisfaction With Care

J Manipulative Physiol Ther. 2014 (Oct);   37 (8):   542–551 ~ FULL TEXT

This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

Conservative Spine Care: Opportunities to Improve the Quality and Value of Care
Popul Health Manag. 2013 (Dec);   16 (6):   390-396 ~ FULL TEXT

A previous article analyzed current practices regarding the use of coronary stents in the chronic stable angina patient. [4] Musculoskeletal disorders represent another diagnostic class that, while usually not life threatening, results in a high prevalence of morbidity and significant societal burden. [5] Low back pain (LBP) management in particular has been linked to inefficiency and waste. [6] This is likely related, in part, to the growing list of treatment approaches recommended for conservative care (pharmacologic and non-pharmaceutical options) and the difficulty in determining the best option for each patient. [7]

Early Predictors of Lumbar Spine Surgery After Occupational Back Injury:
Results From a Prospective Study of Workers in Washington State

Spine (Phila Pa 1976). 2013 (May 15);   38 (11):   953-964 ~ FULL TEXT

Significant worker baseline variables in a multivariate model predicting one or more lumbar spine surgeries within 3 years of claim submission included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and first seeing a surgeon for the injury. Participants younger than 35 years, females, Hispanics, and participants whose first visit for the injury was to a chiropractor had lower odds of surgery.

Chiropractic Episodes and the Co-occurrence of Chiropractic and Health
Services Use Among Older Medicare Beneficiaries

J Manipulative Physiol Ther 2012 (Mar);   35 (3):   168–175 ~ FULL TEXT

Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

Effectiveness of Manual Therapy for Chronic Tension-type Headache:
A Pragmatic, Randomised, Clinical Trial

Cephalalgia. 2011 (Jan);   31 (2):   133–143 ~ FULL TEXT

After 8 weeks (n = 80) and 26 weeks (n = 75), a significantly larger reduction of headache frequency was found for the manual therapy (MT) group (mean difference at 8 weeks, -6.4 days; 95% CI -8.3 to -4.5; effect size, 1.6). Disability and cervical function showed significant differences in favour of the MT group at 8 weeks but were not significantly different at 26 weeks.   Manual therapy is more effective than usual GP care in the short- and longer term in reducing symptoms of chronic tension-type headache (CTTH).

Cost of Care for Common Back Pain Conditions Initiated with
Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy
as First Physician: Experience of One Tennessee-Based
General Health Insurer

J Manipulative Physiol Ther 2010 (Nov);   33 (9):   640-643 ~ FULL TEXT

Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient's costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. This clearly demonstrates the savings that are possible when a patient is permitted to choose a chiropractor, rather than an MD for their care.

Interventions to Improve Adherence to Exercise for
Chronic Musculoskeletal Pain in Adults

Cochrane Database Syst Rev 2010 (Jan 20);   2010 (1):   CD005956 ~ FULL TEXT

Authors' conclusions:

  • The type of exercise prescribed does not appear to influence levels of exercise adherence. Patient preference should therefore be considered in an attempt to increase motivation to initiate and maintain an exercise programme

  • Including simple educational and behavioural strategies, such as providing feedback or using an exercise contract, as part of routine delivery of exercise for chronic musculoskeletal pain may enhance adherence

  • Providing supervised exercise, follow up to reinforce exercise behaviour, and supplementing face-to-face instruction with other material all may have a positive influence on levels of exercise adherence

  • Although supplementing home exercise with a group exercise programme may improve overall physical activity levels, attendance at group sessions may be limited if session times are inconvenient, and missed sessions cannot be rescheduled. The type of exercise setting should therefore again be directed by patient preference

Do Chiropractic Physician Services for Treatment of Low-Back and
Neck Pain Improve the Value of Health Benefit Plans? An
Evidence-Based Assessment of Incremental Impact on
Population Health and Total Health Care Spending

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.

Effects of a Managed Chiropractic Benefit on the Use of
Specific Diagnostic and Therapeutic Procedures in the
Treatment of Low Back and Neck Pain

J Manipulative Physiol Ther 2005 (Oct);   28 (8):   564–569 ~ FULL TEXT

For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a significant reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

An Evaluation of Medical and Chiropractic Provider Utilization
and Costs: Treating Injured Workers in North Carolina

J Manipulative Physiol Ther 2004 (Sep);   27 (7):   442-448 ~ FULL TEXT

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.

Cost Effectiveness of Physiotherapy, Manual Therapy, and General
Practitioner Care for Neck Pain: Economic Evaluation
Alongside a Randomised Controlled Trial

British Medical Journal 2003 (Apr 26);   326 (7395):   911 ~ FULL TEXT

A hands-on approach to treating neck pain by manual therapy may help people get better faster and at a lower cost than more traditional treatments, according to this study.   After seven and 26 weeks, they found significant improvements in recovery rates in the manual therapy group compared to the other 2 groups. For example, at week seven, 68% of the manual therapy group had recovered from their neck pain vs. 51% in the physical therapy group and 36% in the medical care group.
You may also enjoy this WebMD review (Thursday, April 24, 2003) titled:
Manual Therapy Eases Neck Pain, Cheaply: Hands-On Approach Effective,
and More Cost-Effective, than Traditional Treatments

Manual Therapy, Physical Therapy, or Continued Care by a
General Practitioner for Patients with Neck Pain.
A Randomized, Controlled Trial

Annals of Internal Medicine 2002 (May 21);   136 (10):   713–722 ~ FULL TEXT

In this randomized, controlled trial, researchers compared the effectiveness of manual therapy, physical therapy (PT) and continued care by a general practitioner (GP) in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) compared to the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Additionally, patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. The magnitude of the differences between manual therapy and the other treatments (PT or GP) was most pronounced for perceived recovery.

Behavioral and Physical Treatments for Tension-type
and Cervicogenic Headache

Duke University Evidence-based Practice Center ~ 2001 ~ FULL TEXT
In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches.
You might also enjoy Dr. Anthony Rosner's discussion
You may download the full 10-page Adobe Acrobat (PDF) version.
You will also enjoy FCER's announcement on the initial publication of the Duke Report

Cost-effectiveness Studies of Medical and Chiropractic Care for
Occupational Low Back Pain. A Critical Review of the Literature

Spine J. 2001 (Mar);   1 (2):   138-147 ~ FULL TEXT

The current literature suggests that chiropractors and physicians provide equally effective care for OLBP but that chiropractic patients are more satisfied with their care. Evidence on the relative costs of medical and chiropractic care is conflicting. Several methodological deficiencies limit the validity of the reviewed studies. No studies combine high-quality cost data with adequate sample sizes and controls for confounding factors.

The Outcomes and Costs of Care for Acute Low Back Pain Among
Patients Seen by Primary Care Practitioners, Chiropractors,
and Orthopedic Surgeons

New England J Medicine 1995 (Oct 5);   333 (14):   913–917 ~ FULL TEXT

The status at six months was ascertained for 1,555 of the 1,633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors.





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