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Chiropractic Research Abstracts
(Supportive Clinical Research) The following are referenced research studies on chiropractic.1.) The Rand Corporation, in Appropriateness of Spinal Manipulation for Low-back Pain Study, states:23 "In the context of this discussion, the panelists unanimously agreed on the following: An adequate trial of spinal manipulation is a course of twelve manipulations given over a period of up to four weeks, after which, in the absence of documented improvement, spinal manipulation is no longer indicated." In a second part of the study, which involved a mixed panel of back pain experts comes the following: Table 2. Clinical Profiles Appropriate for Manipulation Acute low back pain (<3 wk), 3 to 5 treatments, maximum of 10 before re-evaluation, Previous good response to manipulation, normal or abnormal radiographs, radicular pain, none or minor neurological signs. Subacute low back pain (3-12 wk) Unclear Chronic low back pain (>3 mon), 3 treatments/wk for up to 8 wks before re-evaluation, Previous good response to manipulation, normal radiographs/imaging, no neurological signs. 2.)The Mercy Guidelines, reports visit frequencies ranging from a mean of 4.4 to12.9 (avg. 10.68) over a range of 0 to an avg. of 54.5 days. A study they cite by Triano et al as "more representative of private practice experience" produced a visit range of 1 to 22 sessions. It then suggests the following guideline as a base point: "Return to Pre-episode Status: six to eight weeks; up to three treatments per week." It is stressed that this is for the "uncomplicated case." Defined as "A case where the patient exhibits progressive recovery from an illness or injury at a rate greater than, or equal to, the expectation from the natural history." As quoted from the BACKLetter, September, 1995, "Roughly 8 percent of these episodes lasted longer than six months and entailed more than 20 provider visits", "According to a new community-based RAND study". 3.) The following study is important because it establishes a pre managed care standard of care. Hurwitz, E; Coulter, I; Adams, A; Genovese, B; Shekelle, P; Use of Chiropractic services from 1985 through 1991 in the United States and Canada, Am J Public Health, 1998; 88:771-776 Quotes: In the US sites, about 40% of the patients had private fee-for-service insurance, 20% were self-pay (cash patients), 20% were workers’ compensation or personal injury patients, and 20% had other reimbursement mechanisms (Medicare, private prepaid insurance, and miscellaneous). Sixty-eight percent of the patients sought care for low back pain, while 32% sought care for other reasons. Overall, more than 40% of the patients had been in pain for less than 3 weeks; about 20% had been in pain for longer than 6 months. (3 to <6 months was 14.9%) About 2% of the patients had had previous surgery for low back pain. Overall, 54% of the chiropractic patients at the US sites received x-rays prior to treatment for their current episode of low back pain... Fewer than 2% of all patients with low back pain received advanced imaging (computed tomography or magnetic resonance imaging) during their course of care. The chiropractic visit rates at the US sites...were 101.2...visits per 100 person-years...In comparison the visit rate for physicians in the United States in 1994 was estimated to be 262.5 per 100 person-years. ...the chiropractic visit rates among US sites in the present study were not appreciably different from each other. The small differences in rates between sites are unrelated to differences in chiropractor -to-population ratios. Chart: Low Back Pain, Days duration: Mean 61.7, Median 29, No. Visits: Mean 15.6, Median 7. All Conditions, Days Duration: Mean 54.4, Median 24, No. Visits: Mean 13.5, Median 6. 4.) Carey, B, Back Magic, Health, May/June, 1998: Talking about the Texas Back Institute, "Of the patients who come in here with lower back pain," says Lisa Raines, an administrator at the clinic, "I’d say about 50 percent see a chiropractor first." Eight in ten adults will have a bout of back pain sometime in their lives. In other words, the wizards (surgeons) here at the Texas Back Institute are still very busy...But in a striking change, they see themselves as doctors of last resort. "We have wonderful surgeons here at the institute and we’re certainly not going to lose any of them," he (Triano) goes on "But we’ve just hired two more chiropractors. I think that tells you which direction we’re headed." 5.)Economic issues DOH Minnisota Report: Of the estimated 25 million people who saw a CAM provider in 1994, over 70 percent had seen a provider of chiropractic. (Eisenberg, 1993) A mid-1996 survey of members belonging to Oxford Health Plans reported that one in three members visited an alternative medicine provider in the past two years. (Moore, 1997) However, less than half of the chiropractic users also consulted with an allopathic doctor regarding their specific condition. (Paramore, 1997) If one looks at the a December 31, 1992 profile report it notes 63,295 services for the profession for the year. Using the highest dollar fees schedule for chiropractic care, you get an average dollar amount of $47.93 per service. 6.) Stano study, JMPT 1/1997: Quotes: When controlled for demographic, insurance and condition variables in multiple regression analysis, the results indicate a ratio of 1.61 for medical vs. chiropractic total payments. Total payments across both episodes in both the two- and three-episode cases are substantially greater for physicians than chiropractors (p = .001). Although chiropractors may be seeing a more chronic population overall, we do not see the higher costs associated with such care. However, as previously reported, chiropractic care episodes exhibit longer contact. 7.) A Pilot Study of the Purchase of Manipulation Services for Acute Low Back Pain in the United Kingdom. Neil Scheurmier and Alan C. Breen, D.C., Ph.D. Background: The purchasing arrangements for acute low back pain recommended to UK health ministers by the Clinical Standards Advisory Group (CSAG) in 1994 as a cost neutral way of reducing back pain disability have not been tested in practice. Objectives: To test the CSAG's recommendations in primary care, studying their cost implications and identifying the professional relationships between general practitioners (GP's) and manipulation practitioners. Main Results: Substantial shift of referrals to manipulation practitioners under the scheme. Prospective patients had fewer referrals to secondary care than retrospective patients, few GP consultations, less drug use, few certified sickness days. Prospective patients had shorter waiting times to be seen by manipulating physiotherapists. Chiropractors used X-rays more often than other practitioners. Demonstrable savings in sickness incapacity benefits were evident by following CSAG recommendations. Conclusion: GP's complied with CSAG management recommendation when funding of manipulation services was made available. Implementation was associated with better outcomes generally. A fully funded study including chronic back patients is justified. JMPT 1998; 21:14-18 8.) Kilvaer, A; Rasmussen, G; Soot, T; Kalvenes, S A Comparison Between Referred and Non-referred Patients in Chiropractic Practices in Norway. JMPT; 1997, Sept. 20(7). pp 448-53 Conclusion: Recent studies have shown chiropractic treatment to be a cost-efficient therapy for back-related conditions. The findings in our study indicate that the result of the present system of referral is substantially longer sick-leave time and delayed onset of chiropractic treatment. It is generally accepted that early, effective intervention is the primary method of preventing chronicity. 9.)Mosley, C; Cohen, I; Arnold, R; Cost-Effectiveness of chiropractic Care in a Managed Care Setting. American Journal of Managed Care; 1996 Mar, pp 280-282 Abstract: The cost of healthcare for back and neck pain was substantially lower for chiropractic patients than for non-chiropractic patients ($539 vs $774). Utilization of prescription drugs and diagnostic imaging were significantly greater in the non-chiropractic group, whereas surgical rates and patient satisfaction were nearly identical. The authors conclude that properly managed chiropractic care can yield outcomes, in terms of surgical requirements and patient satisfaction that are equal to those of non-chiropractic care, at a substantially lower cost per patient. 10.) Stano, M Further Analysis of Health Care Costs for Chiropractic and Medical Patients, JMPT, 1994, Sept, 17(7), pp 442-6 Conclusion: 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. 11.) Market Dynamics The follow up to the Mead study, comparing chiropractic care to hospital based PT, concluded that "those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals." Quoting from the BACKLetter, November, 1995, discussing research by Paul G. Shekelle, MD of RAND, et al, concerning patient patterns: "The disparity between chiropractors and other professions in retaining patients over more than one episode of care was substantial. Chiropractors retained 92% of their patients for a second episode of back pain care. General practitioners retained 75% of their patients, osteopaths 75%, orthopedists 50%, internists 22% and other professions 40%."50 13.) Cost and Recurrences of Chiropractic and Medical Episodes of Low-Back Care Monica Smith, DC and Miron Stano, PhD, JMPT Vol 20, Number 1, 1/1997 Study Quotes: As well, our results suggest that a higher retention of chiropractic patients across multiple episodes, probably resulting from greater patient satisfaction, may result in a long-term "shifting" phenomenon of chronic, recurrent cases to chiropractic care. Twice as many chiropractic as medical first episodes (31.6% vs 16.3%) were linked to a recurrence. Medical patients exposed to a chiropractic provider for an intervening episode were 23 times more likely not to return to a medical provider than a medical patient not exposed to chiropractic for an intervening episode. A chiropractic patient with a medical intervening episode was 9 times more likely not to return to chiropractic compared with a chiropractic patient without a medical intervening episode. 14.) RAND Associated Chiropractic with Better Health in the Elderly, Topics in Clinical Chiropractic, Vol 3, No. 2 , Quote from news release: Elderly chiropractic patients report better overall health, have fewer chronic conditions, spend less days in nursing homes and hospitals are more mobile in their communities, and are less likely to use prescription drugs than non- chiropractic patients... In fact, a startling 87% of chiropractic patients described their health status as good to excellent, compared to just 67.8% of non-chiropractic patients--and incredible 19% difference. The results of a three-year randomized trial of people 75 years of age and over revealed better overall health and higher quality of life among those who chose to take advantage of chiropractic care. The demographics of both the chiropractic group and the non chiropractic group are nearly identical in age, gender, education, income, living arrangements, and health insurance. 15.) Kilmer, SE Chiropractic Utilization of Lumbar Magnetic Resonance Imaging: How Accurate Are We Compared With Other Specialties?. JMPT: 1996 Mar. 21(3). pp 176-6 Results: This study showed that DC’s fared better than all providers except for oncologists and general surgeons. Chiropractors fared 2.24% better than orthopedists and 10.06% better than general practitioners, who ironically, DC’s must rely on at times for authorization of MRI’s in certain managed care situations. 16.) White, A Integration of Chiropractic Into Managed Care in a Multidisciplinary Setting, JMPT 1995 Nov/Dec, 18(9). pp 626-7 Abstract:. Enlightened managed care business developers are using chiropractors as primary care health providers and are using centers of excellence that include chiropractors as a major cog in the wheel. The new managed care system directs patients to the least expensive professional who can get the job done most efficiently and accurately. With minimal redirection, the chiropractor is the ideal professional to diagnose and treat the early phases of spinal problems and can easily triage patients to the most appropriate chronic health care provider. 17.) Order from National College of Chiropractic. Jan 1998 Issue of JMPT- Article" Review of the Scientific Literature Relevant to Structural Rehabilitation of the Spine and Posture: Rationale for treatment Beyond the resolution of symptoms" by Troyanovich SJ, Harrison DE, Harrison DD. SAC Committee- CHIROPRACTIC- Research Studies 18.) Report: Complementary Medicine, A report to the Legislature. Minnesota Department of Health, Jan 15, 1998 Quotes: The OAM (Office of Alternative Medicine) established the "Panel on Definition and Description of Alternative Medicine"... The panel proposed the following definition: Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries within CAM and between the CAM domain and the domain of the dominant system are not always sharp or fixed. (OAM, 1997) Complementary medicine is a term which emphasizes the joint use of allopathic and alternative therapies. (Gordon, 1996) The term, " complementary" is different from "alternative" because it implies the use of modalities together with, or as a complement to, the offerings of allopathic medicine. (OAM, 1997) Paradigm Shift reflects a philosophical shift in the definition of healing. 19. Chiropractic "Only Proven Effective Treatment" for Chronic Whiplash Study Says 74% of Acute Whiplash Patients Improved with Chiropractic A new study published in the Journal of Orthopaedic Medicine1 not only points out the superiority of chiropractic care for chronic whiplash patients, but also examines which chronic whiplash patients respond best to chiropractic care. The authors begin the paper by explaining that: "Conventional treatment of patients with whiplash symptoms is disappointing. "A retrospective study by Woodward et al., demonstrated that chiropractic treatment benefited 26 of 28 patients suffering from chronic whiplash syndrome."2 The question was not whether chiropractic was beneficial for acute whiplash patients, but to determine "which patients with chronic whiplash will benefit from chiropractic treatment." The authors interviewed "100 consecutive chiropractic referrals for chronic whiplash symptoms," seven of which were "lost to follow up." They were able to divide the remaining 93 patients into three symptom groups: Group 1: patients with "neck pain radiating in a 'coat hanger'
distribution, associated with restricted range of neck movement but with no neurological
deficit"; The patients underwent an average of 19.3 adjustments over the course of 4.1 months (mean). The patients were then surveyed and their improvement reported as follows: Group 1 Group 2 Group 3 In their discussion, the authors made these observations: "Our study suggests that such a group of nonresponders does exist, represented by group 3. The defining characteristics of patients in this group were the full range of neck movement in association with neck pain, bizarre symptoms, female sex and ongoing litigation. The mean age of the group at 29.5 (16-43) was lower than that of the other two groups (mean 36.8, range 18-65). "The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms. However, our identification of a group of patients who fail to respond to such treatment, highlights the need for a careful history and physical examination before commencing treatment."
Khan S, Cook J, Gargan M, Bannister G. A symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 1999;21(1):22-25.
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