Research

 2016 - Manual and Instrument Applied Cervical Manipulation 
for Mechanical Neck Pain: A Randomized Controlled Trial

J Manipulative Physiol Ther. 2016 (May 12) [Epub] ~ FULL TEXT
Lindsay M Gorrell, MChiro, MRes, PhD, Kenneth Beath, 
Roger M Engel, DO, DC, PhD; Department of Chiropractic, 
Macquarie University, Sydney, NSW, Australia.

The purpose of this study was to compare the effects of 2 different cervical manipulation techniques for mechanical neck pain (MNP). 

Participants with mechanical neck pain (MNP) of at least 1 month's duration (n = 65) were randomly allocated to 3 groups:
(1) stretching (control)
(2) stretching plus manually applied manipulation (MAM), and 
(3) stretching plus instrument-applied manipulation (IAM).

MAM consisted of a single high-velocity, low-amplitude cervical chiropractic manipulation, whereas IAM involved the application of a single cervical manipulation using an (Activator IV) adjusting instrument. Pre-intervention and post-intervention measurements were taken of all outcomes measures. Pain was the primary outcome and was measured using visual analogue scale and pressure pain thresholds. Secondary outcomes included cervical range of motion, hand grip-strength, and wrist blood pressure. Follow-up subjective pain scores were obtained via telephone text message 7 days post-intervention. 

This study demonstrates that a single cervical manipulation is capable of producing immediate and short-term benefits for mechanical neck pain (MNP). The study also demonstrates that not all manipulative techniques have the same effect and that the differences may be mediated by neurological or biomechanical factors inherent to each technique.

2016 - Does Cervical Spine Manipulation Reduce Pain in People With Degenerative Cervical Radiculopathy? A Systematic Review of the Evidence, and a Meta-analysis
Clinical Rehabilitation 2016 (Feb);   30 (2):   145-155
Liguo Zhu, Xu Wei, Shangquan Wang; Department of Spine, Wangjing Hospital, Beijing, People’s Republic of China 

To access the effectiveness and safety of cervical spine manipulation for cervical radiculopathy by means of PubMed, the Cochrane Central Registry of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Wanfang data, the website of Chinese clinical trial registry and international clinical trial registry by US National Institutes of Health. 

Randomized controlled trials that investigated the effects of cervical manipulation compared with no treatment, placebo or conventional therapies on pain measurement in patients with degenerative cervical radiculopathy were searched, and there was moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy. 

2016 - Prognostic Factors for Recurrences in Neck Pain Patients
Up to 1 Year After Chiropractic Care

J Manipulative Physiol Ther. 2015 (Sep 15) [Epub] 
Langenfeld,  A, Humphreys,BK,Swanenburg ,J, Peterson, C, 
CAPHRI School of Public Health and Primary Care, Department of Epidemiology, Maastricht University, Maastricht, The Netherlands. 

Neck pain is a common reason for patients seeking health care. Most people will see a medical practitioner or another health care provider at least once in their lifetime due to neck pain. Those who have experienced an episode of neck pain are likely to have another onset within the next 1 to 5 years. Consequently, The Neck Pain Task Force has described neck pain as an episodic occurrence over one's lifetime with variable degrees of recovery between episodes.

Within a prospective cohort study, 642 neck pain patients were recruited by chiropractors in Switzerland. After a course of chiropractic therapy, patients were followed up for 1 year regarding recurrence of neck pain.

The results of this study revealed that 89% of neck pain patients had recovered from their neck pain episode up to 1 year after receiving chiropractic care. Therefore, 11% of patients reported a new episode or recurrence of their neck pain or had the need for an additional neck pain intervention.  

2014 – Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Neck Pain
J Manipulative Physiol Ther 2014 (Jan);   37 (1):   42–63 
Bryans R, Decina P, Descarreaux M, Duranleau M, Marcoux M, Potter B, Ruegg RP,  Shaw L, Watkin R, White E. 
Guidelines Development Committee (GDC), Newfoundland, Canada. 

The annual prevalence of nonspecific neck pain is estimated to range between 30% and 50%. Persistent or recurrent neck pain continues to be reported by 50% to 85% of patients 1 to 5 years after initial onset. Its course is usually episodic, and complete recovery is uncommon for most patients. Twenty-seven percent of patients seeking chiropractic treatment report neck or cervical problems.  Thus, treatment of neck pain is an integral part of chiropractic practice.

Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.

2013 - A Randomized Controlled Trial Comparing a Multimodal 
Intervention and Standard Obstetrics Care for Low Back and Pelvic Pain in Pregnancy

Am J Obstet Gynecol. 2013 (Apr);   208 (4):   295.e1-7 
George JW, et al; 
Chiropractic Science Division, College of Chiropractic, Logan University, Chesterfield, MO, USA. 

Women commonly experience low back pain during pregnancy. We examined whether a multimodal approach of musculoskeletal and obstetric management (MOM) was superior to standard obstetric care to reduce pain, impairment, and disability in the antepartum period. 

A prospective, randomized trial of 169 women was conducted. Baseline evaluation occurred at 24-28 weeks' gestation, with follow-up at 33 weeks' gestation. Primary outcomes were the Numerical Rating Scale (NRS) for pain and the Quebec Disability Questionnaire (QDQ). Both groups received routine obstetric care. Chiropractic specialists provided manual therapy, stabilization exercises, and patient education to MOM participants. 

The MOM group demonstrated significant mean reductions in Numerical Rating Scale scores (5.8 ± 2.2 vs 2.9 ± 2.5; P < .001) and Quebec Disability Questionnaire scores (4.9 ± 2.2 vs 3.9 ± 2.4; P < .001) from baseline to follow-up evaluation. The group that received standard obstetric care demonstrated no significant improvements. 

A multimodal approach, inclusive of chiropractic manipulation, to low back and pelvic pain in mid pregnancy, benefits patients more than standard obstetric care. 

2013 - 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):953-64. Keeney BJ, Fulton-Kehoe
D, Turner JA, Wickizer TM, Chan KC, Franklin GM. 
Department of Orthopaedics, Geisel School of Medicine at Dartmouth College,
Lebanon, NH

The results of this new study further documents chiropractic care as a first option for back pain relief and surgical avoidance. The study concluded there were reduced odds of surgery for those under age 35, women, Hispanics and those whose first provider was a chiropractor. In total, 42.7 percent of workers who initially visited a surgeon underwent surgery, in contrast to only 1.5 percent of those who first consulted a chiropractor. This important study was conducted by a collaboration of prestigious institutions, including Geisel School of Medicine at Dartmouth College, University of Washington School of Public Health, University of Washington School of Medicine, Ohio State University College of Public Health and the Washington State Department of Labor and Industries. Back injuries are the most prevalent occupational injury in the U.S., and care is commonly associated with one of the most costly treatments – spine surgery. Chiropractic is clearly the most appropriate first treatment option for patients with back pain, and this study confirms the value.

2013 - Dose-response and Efficacy of Spinal Manipulation for Care of
Chronic Low Back Pain: A Randomized Controlled Trial

Spine J. 2013 Oct 16. [Epub ahead of print]
Haas M, et al; 
Center for Outcomes Studies, University of Western States, Portland, OR 97230, USA.

The number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.

2013 - Outcomes of osteopathic manual treatment for chronic low back
pain according to baseline pain severity: Results from the Osteopathic Trial Manual Therapy,

6/14/2013 Clinical Article 
Licciardone JC, et al. 

There was a large effect size for OMT in providing substantial LBP improvement in
patients with HBPS (RR, 2.04; 95% CI, 1.36–3.05; P<0.001). This was accompanied by clinically important improvement in back-specific functioning on the RMDQ (RR, 1.80; 95% CI, 1.08–3.01; P=0.02). Both RRs were significantly greater than those observed in patients with LBPS.

Osteopathic manual treatment was consistently associated with benefits in all other
secondary outcomes in patients with HBPS, although the statistical significance and
clinical relevance of results varied.

Note: The terms manipulation and/or adjustment are synonymous terms and whether undertaken by an osteopath or chiropractor, the action is the same and whatever results obtained through that action may be attributed to that action – the act of manipulation and/or adjustment.

2013 - Randomized Trial Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study; 
Spine: 2013

A study designed to assess changes in pain levels and physical functioning in response to standard medical care (SMC) versus SMC plus chiropractic manipulative therapy (CMT) for the treatment of low back pain (LBP) among 18 to 35-year-old active-duty military personnel, it was concluded that CMT
in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP


2013 – Non-Drug Treatment for Chronic Tension Headache in Teens
American Academy of Pain Management (AAPM) 24th Annual Clinical Meeting.
Abstract #25. Presented September 27, 2013.
P Przekop. 
Betty Ford Center, Rancho Mirage, and Loma Linda University School of Medicine, Loma Linda, California,

Chronic tension-type headache (CTTH), which may affect up to 20% of teens, can
be successfully treated without pharmacologic agents, a new study shows.

The nonpharmacological intervention produced better results in headache frequency, headache pain intensity, general health, social activity, and number of tender points in the trapezius, cervical spine, and superior occipital notch than did pharmacologic treatment (P = .001 for all 5 measures). Over the 6-month period, headache frequency decreased from 23.9 to 16.4 in the pharmacologic treatment group and from 22.3 to 4.9 in the nonpharmacological group. 

2013 - Spinal High-velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain: A Double-blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo
Spine 2013 (Apr 1); 38 (7):540–548

A total of 101 patients with acute LBP (for <48 hr) were recruited from 5 outpatient
practices, exclusion criteria were numerous and strict. Outcomes registered by a
second and blinded investigator included self-rated physical disability, function (SF-
12), off-work time, and rescue medication between baseline and 12 weeks after
randomization. In a subgroup of patients with acute nonspecific LBP, spinal
manipulation was significantly better than nonsteroidal anti-inflammatory drug
diclofenac and clinically superior to placebo.

2013 - Adding chiropractic manipulative therapy to standard medical care
for patients with acute low back pain: results of a pragmatic randomized
comparative effectiveness study.

Spine 2013 Apr 15;38(8):627-34.
Goertz CM, et al;

Patients with chronic and acute pain reporting that they were “much better” or “better” on the Patient Global Impression of Change scale at 1 week after the first chiropractic visit were 4 to 5 times more likely to be improved at both 1 and 3 months compared with patients who were not improved at 1 week. Patients with acute pain reported more severe pain and disability initially but recovered faster. Patients with chronic and acute back pain both reported good outcomes, and most patients with radiculopathy also improved.

2013 - Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study
Spine:15 April 2013;38(8):627-634
Goertz C; Long C; Hondras MA; Petri, R; Delgado R; Lawrence DJ; Owens MA; Edward F; Meeker W

The results of this trial suggest that CMT in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP

2012 - Spinal Manipulation Epidemiology: Systematic Review of Cost Effectiveness - Studies
J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 655–662
Michaleff ZA, Lin CW, Maher CG, van Tulder MW.
The George Institute for Global Health, The University of Sydney, Sydney, NSW, Australia. 

This review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. However, as this conclusion is primarily based on single studies more high quality research is needed to identify whether these findings are applicable in other settings.

2012 - Value of Chiropractic Services at an On-site Health Center; 
J Occupational and Environmental Med 2012 (Aug);54 (8):917–921

This study, offering on-site chiropractic care, versus off-site physical therapy, concluded that: “These results suggest that chiropractic services offered at on-site health centers may promote lower utilization of certain health care services, while improving musculoskeletal function.” Additionally, patients who receive chiropractic treatment often have a more conservative, less invasive treatment profile which can significantly reduce the overall cost of treatment.

2012 - Value of Chiropractic Services at an On-site Health Center
J Occupational and Environmental Med 2012 (Aug);54 (8):917–921 
Krause CA; Kaspin L; Gorman KM; Miller 

These results suggest that chiropractic services offered at onsite health centers may promote lower utilization of certain health care services, while improving musculoskeletal function.

2011 - Long-term Outcomes of Lumbar Fusion Among Workers' Compensation Subjects: An Historical Cohort Study
Spine (Phila Pa 1976) 2011 (Feb 15);   36 (4):   320–331
Nguyen TH, Randolph DC, Talmage J, Succop P, Travis R. 

Division of Epidemiology and Biostatistics, Department of Environmental Health, University of Cincinnati College of Medicine, Milford, OH; Meharry Medical College, Nashville, TN; and Department of Physical Medicine and Rehabilitation, University of Kentucky College of Medicine, Lexington, KY. 

Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.

After two years, only 26 percent of those who had surgery had actually returned to work. That translates to a resounding 74% failure rate! 

It also suggests that the patient has a 257% better chance of returning to work IF HE/SHE AVOIDS SURGERY in the first place!   That's because 67 percent of patients who had the same exact diagnosis, but DIDN'T get surgery, DID return to work.

In another troubling finding, the researchers determined that there was a 41 percent increase in the use of painkillers, particularly opiates, in those who had the surgery. 

“The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs don’t work”, 

says the study’s lead author Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine. 

2011 - Health maintenance care in work-related low back pain and its association with disability recurrence.
Cifuentes M, Willetts J, Wasiak R.
J Occup Environ Med. 2011 Apr;53(4):396-404.
Center for Disability Research at the Liberty Mutual Research Institute for Safety,
Hopkinton, MA, USA. Manuel.Cifuentes@LibertyMutual.com

In work-related nonspecific LBP, the use of health maintenance
care provided by physical therapist or physician services was associated with a
higher disability recurrence than in chiropractic services or no treatment.

2011 - Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome? 
Spine (Phila Pa 1976). 2011
Senna MK; Machaly SA.

Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome? A study carried out at the Rheumatology & Rehabilitation Department at the University of Mansoura, Egypt, and published in journal Spine demonstrated that spinal manipulation therapy is an effective modality in chronic non-specific LBP for short-term effects. Application of spinal manipulation therapy yielded better results when compared with the sham manipulation. Conclusions suggested that maintained spinal manipulation is beneficial to patients of chronic nonspecific LBP particularly to those who gain improvement after initial intensive manipulation to maintain the improved post-treatment pain and disability levels

2011 - A Hospital-Based Standardized Spine Care Pathway: Report of a Multidisciplinary, Evidence-Based Process
J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106

A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway, utilizing a multidisciplinary, evidence-based, standardized process, to improve clinical outcomes, and to reduce the costs associated with treatment and diagnostic testing. 518 consecutive patients were assessed and 83% (432) were classified and then treated by doctors of chiropractic and/or physical therapists.
95% of patients treated by DCs rated their care as "excellent." This was accomplished with a relatively low cost and with high patient satisfaction. 

The authors concluded that “inter-professional collaboration between doctors of chiropractic, physical therapists, and medical doctors within teams improved spine
care; that promotion of care coordination reduced unnecessary testing and procedures; and the standardization of LBP management reduced practice variations and significantly reduced the costs of care.”

2011 - Cost-effectiveness of Guideline-endorsed Treatments for Low Back Pain: A Systematic Review
Eur Spine J. 2011 (Jan 13) [Epub ahead of print]

This 2011 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). Massage alone was unlikely to be cost-effective. 

This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioral therapy for sub-acute or chronic LBP. It also found no evidence at all on the cost-effectiveness of medication for low back pain.

2011 - Health Maintenance Care in Work-Related Low Back Pain and its association with Disability Recurrence
Journal of Occupational and Environmental Medicine 2011 (Apr); 53 (4):396–404;
http://www.ncbi.nlm.nih.gov/pubmed/21407100 

This study found that you are twice as likely to end up disabled if you get your care from a Physical Therapist, rather than from a Doctor of Chiropractic (DC), and that patients were 60% more likely to be disabled if they choose an MD to manage their care, rather than a DC.


2011 - Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence
Journal of Occupational and Environmental Medicine
2011 (Apr); 53 (4):396–404
Willetts J, Wasiak R.
From the Center for Disability Research at the Liberty Mutual Research Institute for
Safety (Cifuentes & Willetts) and University of Massachusetts Lowell (Cifuentes), Hopkinton, Mass; and Center for Health Economics & Science Policy at United BioSource Corporation, London, United Kingdom (Dr Wasiak).

This study is unique in that it was conducted by the Center for Disability Research at the Liberty Mutual Research Institute for Safety and the University of Massachusetts Lowell, Hopkinton, Mass; and the Center for Health Economics & Science Policy at United BioSource Corporation, London, United Kingdom.

Their objective was to compare the occurrences of repeated disability episodes between types of health care providers, who treat claimants with new episodes of work-related low back pain (LBP). They followed 894 patients over 1-year, using workers’ compensation claims data.

By controlling for demographics and severity, they determined the hazard ratio (HR) for disability recurrence between 3 types of providers:

Physical Therapists (PT),
Physicians (MD), or
Chiropractors (DC).

The results are quite interesting:
For PTs     : HR = 2.0
For MDs     : HR = 1.6
For DCs     : HR= 1.0

Statistically, this means you are twice as likely to end up disabled if you got your
care from a Physical Therapists (PT), rather than from a Doctor of Chiropractic.
You’re also 60% more likely to be disabled if you choose a Physician (MD) to
manage your care, rather than a Doctor of Chiropractic.

The authors concluded:
“In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than with chiropractic services.”

2011 - A Hospital-Based Standardized Spine Care Pathway: Report of a Multidisciplinary, Evidence-Based Process
J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106
Paskowski I, Schneider M, Stevans J, Ventura JM, Justice BD. Medical Director,
Medical Back Pain Program, Jordan Hospital, Plymouth, Mass.
http://www.chiro.org/LINKS/ABSTRACTS/Hospital-Based Standardized_Spine.shtml 

A health care facility (Jordan Hospital) implemented a multidimensional spine care
pathway, utilizing a multidisciplinary, evidence-based, standardized process, to
improve clinical outcomes, and to reduce the costs associated with treatment and
diagnostic testing. 518 consecutive patients were assessed and 83% (432) were
classified and then treated by doctors of chiropractic and/or physical therapists.

95% of patients treated by DCs rated their care as “excellent.” This was
accomplished with a relatively low cost and with high patient satisfaction. The
authors concluded that:

 “interprofessional collaboration between doctors of chiropractic, physical therapists, and medical doctors within teams improved spine care; that promotion of care coordination reduced unnecessary testing and procedures; and the standardization of LBP management reduced practice variations and significantly reduced the costs of care.”

2011 -  Does maintained Spinal manipulation therapy for chronic nonspecific low back pain result in better long term outcome?
Spine (Phila Pa 1976). 2011 Jan 17. [Epub ahead of print]
Senna MK, Machaly SA.
Rheumatology and Rehabilitation Department, Mansoura Faculty of Medicine, Mansoura University.

SMT is effective for the treatment of chronic non-specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy

2010 - Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults.
JAMA. 2010 Apr 7;303(13):1259-65.
Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG.
Department of Family Medicine, Mail Code FM, Oregon Health and Science University, Portland, OR 97239, USA. 

In recent decades, the fastest growth in lumbar surgery occurred in older patients with spinal stenosis. Trials indicate that for selected patients, decompressive surgery offers an advantage over non-operative treatment, but surgeons often recommend more invasive fusion procedures. Comorbidity is common in older patients, so benefits and risks must be carefully weighed in the choice of surgical procedure. 

Among Medicare recipients, between 2002 and 2007, the frequency of complex fusion procedures for spinal stenosis increased while the frequency of decompression surgery and simple fusions decreased. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.
Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone.

2010 - LIBERTY MUTUAL RESEARCH INSTITUTE FOR SAFETY
ANNUAL REPORT OF SCIENTIFIC ACTIVITIES 2010


Liberty Mutual is the largest private provider of workers compensation insurance and services in the United States. Liberty Mutual is an industry leader in occupational health and safety, managed care, occupational rehabilitation and return-to-work programs. Additionally, Liberty Mutual is the only insurer to operate its own Research Center for Safety and Health as well as a Medical Service Center that specializes in rehabilitation programs. Liberty International Underwriters has full access to all of Liberty Mutual's facilities and market strengths.

This landmark conference, held in Angers, France, was the first to focus exclusively
on work disability prevention research and the promotion of safe and sustained
return to work.

Researchers found that the patients who had received passive physical therapy services had a significantly greater number of disability days than those who received no therapy. Study participants who received comprehensive ergonomics training reported significantly fewer musculoskeletal symptoms of pain/discomfort than those who received minimal training.

...cases that had early MRIs were more likely to have prolonged disability, higher
medical costs, and greater utilization of surgery.

At one year, 90% of subjects in the intervention groups were working, compared
with 68% in the control group. Similarly, the improvements in pain...were greater
in both intervention groups.

...patients treated by physical therapists or physicians have a higher rate of
recurrence than those treated by chiropractors....

2010 - 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

This important 2010 study evaluated low back pain care for Blue Cross Blue Shield of Tennessee’s intermediate and large group fully insured population over a two-year period. The 85,000 BCBS subscribers in the insured study population had open access to MDs and DCs through self-referral, and there were no limits applied to the number of MD/DC visits allowed and no differences in co-pays. Thus, the data from this study reflect what happens when chiropractic and medical services compete on
a level playing field. 

The researchers, led by an actuary, compared the costs of low back pain care initiated with a doctor of chiropractic with care initiated through a medical doctor or osteopathic physician. They found that costs for the chiropractic group were 40 percent lower. Even after factoring in the severity of the conditions
with which patients presented, costs when initiating care with a DC rather than an MD/DO were 20 percent lower. 

The researchers concluded that insurance companies that restrict access to chiropractic care for low back pain treatment may inadvertently pay more for care than they would if they removed such restrictions.

According to this analysis, had all of the low back cases initiated care with a DC,
this would have led to an annual cost savings of $2.3 million for BCBS of Tennessee.

2010 - 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
Manipulative Physiol Ther 2010 (Nov); 33 (9): 640–643
http://www.jmptonline.org/article/S0161-4754%2810%2900216-2/abstract 

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.

2010 - Effectiveness of manual therapies: the UK evidence report.
Chiropr Osteopat. 2010 Feb 25;18:3.
http://www.ncbi.nlm.nih.gov/pubmed/20184717 
Bronfort G, Haas M, Evans R, Leininger B, Triano J.
Northwestern Health Sciences University, Bloomington, MN, USA.

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. 

Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation. Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

2009 - 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

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.

2009 - 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
Aspegren D, et al; 
Department of Rehabilitation, University of Colorado School of Medicine, Lakewood, CO

This retrospective case series study evaluated data on 100 patients referred for chiropractic care of work-related spinal injuries involving workers' compensation claims.

The study identified positive effects of chiropractic management included in integrative care when treating work-related neck or back pain. Improvement in both functional cores and subjective response was noted in all 3 time-based phases of patient status (acute, subacute, and chronic).

2009 - 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

Injured workers with either an acute or subacute injury had significantly lower post-treatment FRI scores compared with individuals with a chronic injury. The FRI change scores were significantly greater in the acute group compared with either he subacute or chronic injured workers. Workers in all categories showed improved post-treatment tolerance for work-related activities and significantly lower
post-treatment 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).

2009 - Consumer Reports Lists Chiropractic Patients As Most Satisfied; Consumer Reports ~May 2009 

A study in the May 2009 issue of Consumer Reports shows that hands-on therapies were tops among treatments for relief of back pain. The study, which surveyed more than 14,000 consumers, was conducted by the Consumer Reports Health Ratings Center. The report states that, “eighty-eight percent of those who tried chiropractic manipulation said it helped a lot, and 59 percent were ‘completely’ or ‘very’ satisfied with their chiropractor.”

2009 - Estimating Cost of Care for Patients With Acute Low Back Pain: A Retrospective Review of Patient Records
Crow WT; Willis DR. 
Florida Hospital East Orlando, Orlando.

A total of 1556 patients and 2030 episodes of care met inclusion criteria. Compared with subjects in the control group, individuals in the OMT group had an average of 0.5 more office visits per EOC, resulting in 38% more office visits. However, OMT patients had 18.5% fewer prescriptions written, 74.2% fewer radiographs, 76.9% fewer referrals, and 90% fewer magnetic resonance imaging scans. In the OMT group, total average costs were $38.26 lower (P=.02), and average prescription costs were $19.53 lower (P<.001). Patients in the OMT group also had $63.81 less average radiologic costs (P<.0001). Osteopathic manipulative treatment may reduce costs for the management of acute LBP. 

2008 - Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-based Case-control and Case-crossover Study
SPINE (Phila Pa 1976) 2008 (Feb 15);   33 (4 Suppl):   S176–183
Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ
Centre of Research Expertise for Improved Disability Outcomes, University Health Network Rehabilitation Solutions, Toronto Western Hospital, Toronto, ON, Canada. 

The United Nations and the World Health Organization created the Neck Pain Task Force in 2002 as part of the larger “Bone and Joint Decade” project. The findings of this task force was published a supplemental issue of the prestigious Spine Journal in 2008. 

Their findings resulted from a six-year review of more than 31,000 research citations, and a subsequent analysis of over 1,000 studies. The multi-disciplinary report, involving specialists from 19 different areas of expertise, and from eight different collaborating universities in four countries, is widely regarded as one of the most extensive reports on the subject of neck pain ever developed, and it offers the most current perspective on the scientific evidence related to the care and management of neck pain. 

Out of over one million patient years (the length of time the total number of patients had been under care), 818 hospitalized vertebrobasilar artery stroke patients were identified. In the patients below the age of 45, those actually experiencing a stroke were three times more likely to have visited either their chiropractor or their PCP than the control patients. Those over 45 showed no increased association between experiencing a stroke and having seen their chiropractor than those experiencing a stroke and having seen their PCP.

The authors concluded that vertebrobasilar artery stroke is a rare event in the population.

There is an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age.

There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups.

The authors found no evidence of excess risk of VBA stroke associated with chiropractic care.

The increased risks of vertebrobasilar artery stroke associated with chiropractic and physician visits is likely explained by patients with vertebrobasilar dissection-related neck pain and headache consulting both chiropractors and primary care physicians before their VBA stroke.

2007 - Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Ann Intern Med. 2007;147(7):478-491.
Chou R; Qaseem A; Snow ; Casey D; Cross Jr JT; Shekelle P; Owens DK.
Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society; Low Back Pain Guidelines Panel.

For patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits” for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, spinal manipulation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation 

2007 - Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. 
Ann Intern Med 2007;147:492-504
Chou R, Huffman LH.

Researchers sought to determine the benefits and harms of acupuncture, back schools, spinal manipulation, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical, nerve stimulation, and ultrasonography), and yoga for acute or chronic low back pain (with or without leg pain). Researchers conducted MEDLINE searchers and the Cochrane Database of Systematic Reviews and graded the methodologies of the studies. Researchers concluded that there was good evidence that cognitive-behavioral therapy, spinal manipulation, exercise, and interdisciplinary rehabilitation were effective for chronic or subacute low back pain.

2007 - 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

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 non-pharmaceutical approaches generates reductions in both clinical and cost
utilization when compared with PCPs using conventional medicine alone.

2007 - Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials. 
Vernon H, Humphreys K, Hagino C.
J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):215-27.

Neck pain is a common ailment, with approximately 10-15% of the population suffering from it at any given time. The researchers in this study reviewed 1980citations and found 13 high quality trials utilizing manipulation or manual therapy. Their review found that the benefit from manipulation was greater.
The long-term data regarding spinal manipulation for chronic neck pain was not as conclusive. However, the results demonstrated a great benefit with treatment up to 104 weeks. The spinal mobilization trials also showed very good benefit at a 6 to 7 week outcome point, with 70% of patients having full recovery or important improvement at that point. The researchers attempted to determine whether the benefit could be the natural history and placebo effect and compared these trials with a separate group of controlled no-treatment patients. The researchers concluded that the benefit noted in this review
exceeded the placebo effect and natural history of the no treatment group.

2007 - 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
http://www.ncbi.nlm.nih.gov/pubmed/17509435 

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 non-surgical non-pharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.

2006 - History and Overview of Theories and Methods of Chiropractic: A Counterpoint
Clin Orthop Relat Res 2006 (Mar);444:243–249
DeVocht JW

Spinal manipulation has been used for its therapeutic effects for at least 2500 years. Chiropractic as we know it today began a century ago in a simplistic manner but has developed into to a well-established profession with 33 colleges throughout the world. During the initial, developing years, many people thought it had little more value than a placebo. Nevertheless, there have always been satisfied recipients of chiropractic care and the profession slowly gained prominence - mostly by word of mouth. 

As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective. Other studies have shown that chiropractic care compared with medical care is safer, costs no more and often costs much less, and has consistently greater patient satisfaction for treatment of similar conditions. Consequently, there is now better public and professional opinion of chiropractic with coverage by insurance companies and government agencies. That trend is likely to continue.

2006 - Childs JD, Flynn TW, Fritz JM. A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain.
Man Ther. 2006 Nov;11(4):316-20.

In this study, the researchers divided 131 low back pain patients into groups receiving either manipulation and exercise or exercise alone. The researchers attempted to determine the effect of a public policy that does not routinely offer manipulation for patients with low back pain. There are large direct and indirect costs associated with prolonged low back pain disability and this study attempted to evaluate the risks associated with not treating low back pain patients with manipulation. 

The researchers attempted to determine the Number Needed to Treat (NNT) to prevent one patient from worsening in disability. They analyzed their treatment data and concluded that deciding not to treat a low back pain patient with manipulation is not innocuous or conservative. Patients treated with exercise only were 8 times more likely to experience worsening in disability at 1 week. Acute patients with symptoms not distal to the knee and fewer than 16 days were linked to a 66% probability that they would have a 50% reduction in disability over a 1-week period.

2006 - Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.
Spine J. 2006 Mar-Apr;6(2):131-7
Santilli V, Beghi E, Finucci S.

This study included 102 patients with acute back and/or leg pain of moderate to severe intensity and MRI evidence of disc protrusion. The patients received a maximum of 30 manipulations or simulated manipulations over a 30 day period.

28% of the manipulation group became pain-free locally vs. only 6% in the sham group. 55% of the manipulation group experienced absence of radicular symptoms compared to 20% of the no manipulation group. The manipulation group also had a significant decrease in use and prescriptions for NSAIDs.

2006 - A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study.
BMC Musculoskelet Disord. 2006 Feb 23;7:16.
Murphy DR, Hurwitz EL, Gregory AA, Clary R.

Non-surgical treatment for spinal stenosis is often recommended but clinical outcome efficacy data has been little-studied. 57 patients with leg pain and lumbar spinal stenosis (LSS) documented by MRI or CT were treated at the Rhode Island Spine Center with distraction manipulation and neural mobilization.

Neural mobilization is a nerve root mobilization technique applied by having the practitioner perform a series of maneuvers moving the foot alternatively into extension and flexion while flexing the hip and extending the knee. The distraction manipulation was theorized to break up peri-radicular adhesion, thereby releasing nerve root entrapment and restoring vascular function. The patients were also given cat and camel exercises to complement the manual techniques.

In general, patients were treated 2-3 times per week for 3 weeks then reevaluated for outcome measurements and continued on a reduction of frequency basis for a mean number of 13 treatments. Improvement in disability and patient-rated changes were both significant and clinically meaningful. Long term follow-up at 16.5 months found patient- rated improvement to be 76% while disability measured by Roland Morris Disability Questionnaire was 73%.

The researchers concluded this treatment approach is a viable alternative to surgery and most patients should be treated non-surgically before considering an operation.

2006 - Does the evidence for spinal manipulation translate into better outcomes in routine clinical care for patients with occupational low back pain?
Spine J. 2006 May-Jun;6(3):289-95.
Fritz JM, Brennan GP, Leaman H

Researchers examined the effect of thrust manipulation on patient diagnoses with occupational low back pain receiving worker’s compensation. They stated that thrust manipulation is evidence-based, but is underutilized by physical therapists in the occupational setting. 578 patients were treated with either thrust manipulation, no-thrust manipulation or no manipulation. The thrust patients had a 66% reduction in Oswestry scores over a period of four sessions in 2.5 weeks. The thrust patients also had more improvement in both pain and disability compared to the no manipulation patients and the duration of care was shorter. The cost of physical therapy was also found to be greater in the non-thrust techniques group.

2006 - Efficacy Of Treating Low Back Pain And Dysfunction Secondary To
Osteoarthritis: Chiropractic Care Compared With Moist Heat Alone

J Manipulative Physiol Ther 2006;29:107Q114)
KL Beyerman, RN, EdD,M Palmerino.

250 subjects with low back pain thought to be secondary to osteoarthritis were randomized to receive 20 treatments of either chiropractic care (flexion/distraction with spinal manipulation) with hot moist packs or hot moist packs alone. 

Chiropractic care with heat was found to be far superior to heat alone utilizing various outcome measures including pain intensity, ROM and activities of daily living. The chiropractic group had rapid improvement in personal care, walking, sitting and social life, while the moist heat alone group had no improvement of these factors.

2006 - Factors Associated With Patient Satisfaction With Chiropractic Care: Survey and Review of the Literature
J Manipulative Physiol Ther 2006 (Jul); 29 (6):455–462
http://www.ncbi.nlm.nih.gov/pubmed/16904491 

The results here generally confirm the findings elsewhere in the literature. Of the 23% of the adult population who have ever visited a chiropractor, overall rates of satisfaction are once again found to be quite high (83% satisfied or better) and the number dissatisfied is quite low (less than 10% dissatisfied or very dissatisfied). This is remarkable given the fact that much of the financial burden of the care is
borne by patients, and the preponderance of care is for difficult chronic problems of back and neck.

2006 - Symptomatic Outcomes and Perceived Satisfaction Levels of Chiropractic Patients with a Primary Diagnosis Involving Acute Neck Pain
J Manipulative Physiol Ther 2006 (May); 29 (4):288–296
http://www.ncbi.nlm.nih.gov/pubmed/16690383 

A total of 115 patients were contacted, of whom 94 became study participants, resulting in 60 women (64%) and 34 men. The mean age was 39.6 years (SD, 15.7). The mean number of visits was 24.5 (SD, 21.2). Pain levels improved significantly from a mean of 7.6 (median, 8.0) before treatment to 1.9 (median, 2.0) after treatment (P < .0001). The overall patient satisfaction rate was 94%.

2005 - 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
http://www.ncbi.nlm.nih.gov/pubmed/16226623 

For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a 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.

2005 - Cost-effectiveness of Medical and Chiropractic Care for Acute and Chronic Low Back Pain
J Manipulative Physiol Ther 2005 (Oct);28 (8):555–563

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.

2005 - 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

For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a 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.

2005 - Cost-effectiveness of Medical and Chiropractic Care for Acute and Chronic Low Back Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 555–563
http://www.ncbi.nlm.nih.gov/pubmed/16226622 

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.

2004 - Clinical and Cost Outcomes Of An Integrative Medicine IPA
J Manipulative Physiol Ther 2004 (Jun); 27 (5): 336–347

In 1999, a large Chicago HMO began to utilize doctors of chiropractic (DCs) in a primary care provider role. The DCs focused on assessment and evaluation of risk factors and practiced with a non-pharmaceutical/non-surgical approach. Insurance claims and patient surveys were analyzed to compare clinical outcomes, costs and member satisfaction with a normative control group. During the 4-year study, this integrative medical approach, emphasizing a variety of complementary and  alternative medical (CAM) therapies, resulted in lower patient costs and improved clinical outcomes for patients. 

The patients who went to DCs as their primary care providers had 43 percent decreases in hospital admissions, 52 percent reductions in pharmaceutical costs and 43 percent fewer outpatient surgeries and procedures.

2004 - Chiropractic Care: Is It Substitution Care or Add-on Care in Corporate Medical Plans?
J Occup Environ Med 2004 (Aug); 46 (8): 847–855
http://www.ncbi.nlm.nih.gov/pubmed/15300137 

In this study, the claims of 8 million members insured by a managed health plan were evaluated to determine how patients utilize chiropractic treatment when they have a chiropractic benefit. They found that patients use chiropractic as a direct substitution for medical care, choosing chiropractic 34 percent of the time. Having a chiropractic benefit rider did not increase the number of patients seeking care for  neuromusculoskeletal complaints.

2004 - Comparative Analysis of Individuals with and Without Chiropractic Coverage: Patient Characteristics, Utilization, and Costs
Archives of Internal Medicine 2004 (Oct 11); 164 (18): 1985–1892
http://archinte.ama-assn.org/cgi/content/full/164/18/1985 

A 4-year retrospective claims data analysis comparing more than 700,000 health plan members within a managed care environment found that members had lower annual total health care expenditures, utilized x-rays and less MRIs, had less back surgeries, and for patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399).

The authors concluded: "Access to managed chiropractic care appears to 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.

2004 - 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
http://www.ncbi.nlm.nih.gov/pubmed/15389175 

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.

2004 - Clinical and Cost Outcomes of an Integrative Medicine IPA
J Manipulative Physiol Ther 2004 (Jun) ; 27 (5):336–347
http://www.ncbi.nlm.nih.gov/pubmed/15195041 

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.

2004 - Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain: A Systematic Review and Best Evidence
Bronfort G, Haas M, Evans R, Bouter L.Spine J. 2004 May-Jun;4(3):335-56. Review

The authors categorized 43 randomized controlled trials to assess the efficacy of spinal manipulative therapy (SMT) for back and neck pain. Overall, there was limited to moderate evidence (depending on the study) that spinal manipulative treatment for both chronic and acute lower back pain was more effective and provided more short-term relief than many other types of care, including prescription drugs, physical therapy and home exercise.

There was significant evidence that spinal mobilization was superior to physical therapy and some medical regimens for some types of neck pain. The data synthesis in the study suggests that recommendations can be made with some confidence regarding the use of SMT and/or mobilization as a viable option for the treatment of both low back pain and neck pain.

2004 - A Practice-Based Study of Patients with Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-Week to 48-Month Follow-up
J Manipulative Physiol Ther 2004 (Mar); 27 (3): 160–169
http://www.ncbi.nlm.nih.gov/pubmed/15129198 

This study found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients' first year of symptoms.

2004 - Efficacy of Preventive Spinal Manipulation for Chronic Low Back Pain and Related Disabilities: A Preliminary Study.
Journal of Manipulative and Physiological Therapeutics 2004;27:509-14.
Descarreaux M, Blouin J, Drolet M, Papadimitriou S, Teasdale N.

Non-specific back pain patients were treated with twelve chiropractic spinal manipulations over a one-month intensive period. The patients were then divided into two groups, one group acting as a control and another receiving maintenance spinal manipulation every three weeks for nine months. Both groups improved with chiropractic care and maintained that improvement during the tenth month study. 

The group receiving maintenance treatment every three weeks reported better disability scores after nine months than the control group. This study appears to confirm previous reports showing that low back pain and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and a reduction in the amount and intensity of pain episodes after an acute phase of treatment.

2004 - United Kingdom Back Pain, Exercise and Manipulation Randomized Trial: Cost Effectiveness of Physical Treatments for Back Pain In Primary Care
British Medical Journal 2004 (Dec 11); 329 (7479): 1381

This study compared the benefits of spinal manipulation and exercise to “best care” in general practice for patients consulting for back pain. 1,287 patients were divided into treatment groups and followed for more than one year. Patients receiving manipulation and exercise had lower relative treatment costs and experienced more treatment benefits than those treated with general medical care. 

The authors believe that this study convincingly demonstrated that manipulation alone and manipulation followed by exercise provided cost-effective additions to general practice.

2004 - Cost Effectiveness of Physical Treatments for Back Pain in Primary Care 
British Medical Journal 2004 (Dec 11); 329 (7479): 1381
http://www.bmj.com/content/329/7479/1381.full 

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.

2004 - Comparative Analysis of Individuals With and Without Chiropractic CoveragePatient Characteristics, Utilization, and Costs 
Arch Intern Med. 2004;164(18):1985-1992; 
Legorreta AP, et al

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

2003 - A Randomized Trial of Combined Manipulation, Stabilizing Exercises, and Physician Consultation Compared to Physician Consultations Alone for Chronic Low Back Pain.
Spine 2003; 28: 2185-2191.
Niemisto L, Lahtinen-Suopanki T, et al.

In this study, researchers randomly assigned 240 chronic low back pain patients to either manipulative treatment or a medical physician consultation. The manipulative group received four weeks of physician consultation, manipulation and exercise from an experienced manual therapist, while another group received only physician consultation and an educational booklet. Outcome was measured by pain intensity and back-specific disability. Both groups improved, however the patients treated with manipulation and exercise had more reduced pain and better self-rated disability than the consultation
alone group.

2003 - Manual Therapy and Exercise Therapy in Patients with Chronic Low Back Pain.
Spine 2003; 28: 525-532.
Aure O, Nilsen J, Vasseljen O.

Patients complaining of lower back or radicular pain were randomized to either manual therapy or exercise for a period of two months. Both groups of patients improved with treatment, however the manual therapy group showed significantly greater improvement on both short and long- (1 year) term followup. The researchers in this study also observed a considerable reduction in sick leave for the manual therapy group.


2003 - Chronic spinal pain - a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. 
Spine 2003

A randomized, controlled clinical trial published in the journal Spine reveals that chiropractic manipulation (adjustment) is superior to both drugs and acupuncture in the treatment of chronic spinal pain (people with pain lasting more than 13 weeks). 

The study, conducted at a multidisciplinary spinal pain outpatient unit in an Australian public hospital, involved 115 patients randomly assigned to receive one of three interventions: medication, needle acupuncture or chiropractic manipulation. One of the study's most remarkable findings was that patients in the manipulation group reported a 47 percent improvement on a general overall health questionnaire, compared to only 15 percent for the acupuncture group and 18 percent for the medication group.

2003 - Chronic Spinal Pain - A Randomized Clinical Trial Comparing Medication, Acupuncture and Spinal Manipulation. 
Spine 2003; 28: 1490-1503.
Giles L, Muller R.

In this study, patients with chronic lower back pain of at least 13 weeks duration were randomly assigned either to medication, needle acupuncture or spinal manipulation. The results provided evidence that in patients with chronic spinal pain, manipulation results in greater short-term improvement than acupuncture or medication. The patients receiving spinal manipulation also reported a much higher full recovery rate (27%) than either those receiving acupuncture (9%) or medication (5%).

2003 - Patterns and Perceptions of Care for Treatment of Back and Neck Pain: Results of a National Survey.
Spine 2003;28(3): 292-298.
Wolsko P, Eisenberg D, Davis R, Kessler R, Phillips R.

Researchers conducted a national telephone survey of 2,055 adults, asking if they had back or neck problems during the past 12 months, and if yes, what type of treatment was received and how helpful was it. 33 percent of those surveyed reported having back or neck pain during the last year; 20 percent sought chiropractic care. Chiropractic providers were perceived as having been very helpful for back or neck pain in 61 percent of the cases, in contrast to only 27 percent who perceived their medical care as being very helpful. 72 percent of those treated by a chiropractor reported the treatment as very helpful, compared to only 19 percent of those who had seen conventional providers.




2003 - Chiropractic Treatment of Workers' Compensation Claimants in the State of Texas
MGT of America (National research/consulting)

This retrospective study of workers’ compensation claims from 1996 to 2001 was conducted by an independent, national research and consulting firm to determine the use and efficacy of chiropractic care in Texas. The researchers reviewed 900,000 claims during that time period to determine if chiropractic was cost-effective compared to medical treatment. They found that chiropractor treatment
costs were the lowest of all providers and that chiropractic care was associated with significantly lower costs and more rapid recovery in treating workers with low-back injuries. The study data demonstrated that increased utilization of chiropractic care could lead to declining costs relative to lower back injuries.

2003 - Conservative Spine Care: The State of the Marketplace and Opportunities for Improvement 
OptumHealth White Paper

Data from OptumHealth (United Health Care) indicate that a more efficient treatment path typically begins with a patient consulting a chiropractor - not a PCP, Orthopedic Surgeon or Physical therapist, but a chiropractor! The literature supports the fact that this path tends to lead to interventions that are more closely aligned with recommended treatment guidelines and ultimately result in more favorable solutions at more reasonable costs.

2003 - 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
http://www.bmj.com/content/326/7395/911.full 

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.

2003 - Chiropractic treatment of workers' compensation claimants in the state of Texas
MGT of America, Austin, Texas ~ February 2003
http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=9212 

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 interesting: 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.

2002 - Comparing the Satisfaction of Low Back Pain Patients Randomized to Receive Medical or Chiropractic Care: Results From the UCLA Low Back Pain Study.
American Journal of Public Health 2002; 92:1628-1633.
Hertzman-Miller R, Morgenstern H, Hurwitz E,et al.

Approximately one third as many back pain patients seek chiropractic care compared to those who seek medical care. In earlier randomized clinical trials, investigators found spinal manipulation to have similar or better rates of patient satisfaction when compared to medical approaches such as physical
therapy, McKenzie method and standard medical therapy. This study examined the differences in satisfaction between patients assigned to either medical care or chiropractic care in a managed care organization. In this randomized trial, the chiropractic patients were more satisfied with their back care after 4 weeks of treatment. 

The researchers concluded that providers in managed care organizations may be able to increase the satisfaction of their low back pain patients by communicating advice and information to patients about their condition and treatment.

2002 - Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial
Ann Intern Med 2002 (May 21); 136 (10): 713-722
http://www.ncbi.nlm.nih.gov/pubmed/12020139 

Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared. In this study, manual therapy was a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.

2002 - Comparing the Satisfaction of Low Back Pain Patients Randomized to Receive Medical or Chiropractic Care: Results from the UCLA Low-back Pain Study
Am J Public Health 2002 (Oct); 92 (10): 1628–1633
Hertzman-Miller RP, Morgenstern H, Hurwitz EL, Yu F, Adams AH, Harber P,
Kominski GF
Department of Epidemiology, UCLA School of Public Health, University of California-
Los Angeles, Los Angeles, CA, USA. http://www.ncbi.nlm.nih.gov/pubmed/12356612 

Approximately one third as many back pain patients seek chiropractic care compared to those who seek medical care. In earlier randomized clinical trials, investigators found spinal manipulation to have similar or better rates of patient satisfaction when compared to medical approaches such as physical therapy,
McKenzie method and standard medical therapy.

2002 - Manual Therapy, Physical Therapy or Continued Care by a General Practitioner for Patients with Neck Pain.
Annals of Internal Medicine 2002;136: 713-7220.
Hoving J, Koes B, De Vet H, et al

In a 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.

2001 - Patient Satisfaction with the Chiropractic Clinical Encounter: Patient satisfaction with the chiropractic clinical encounter
Karen T. Boulanger, BA, Cheryl Hawk, DC, PhD, and Cynthia R. Long, PhD. Palmer
Center for Chiropractic Research, Davenport, IA 
http://apha.confex.com/apha/129am/techprogram/paper_19986.htm 

Data were collected from 2986 adult patients of 172 U.S. and Canadian chiropractors in a practice-based research program over a one-week period in November 1999. Of the 1822 patients reporting pain, 56.2% rated the care they received for it as "excellent," 30.6% "very good;" 9.3% "good;" 1.3% "fair;" and 0.2% "poor;" 2.0% did not respond. Patients were quite satisfied with the care they received with 83% reporting that their chiropractor always listened carefully to them and always explained things in a way they could understand; 88% reported their chiropractor always showed respect for what they had to say; 78% felt their chiropractor always spent enough time with them.

2001 - Utilization, Cost, and Effects Of Chiropractic Care On Medicare Program Costs
Muse and Associates. American Chiropractic Association 2001

This study examines cost, utilization and effects of chiropractic services on Medicare costs. The study compared program payments and service utilization for Medicare beneficiaries who visited DCs and those who visited other types of physicians. The results indicated that chiropractic care could reduce Medicare costs. Medicare beneficiaries who had chiropractic care had an average Medicare payment of
$4,426 for all Medicare services. Those who had other types of care had an average of $8,103 Medicare payment for all Medicare services. The per claim average payment was also lower with chiropractic patients, having an average of $133 per claim compared to $210 per claim for individuals who did not have chiropractic care.

2000 - Patient characteristics, practice activities, and one- month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: a practice-based feasibility study.
Journal of Manipulative and Physiological Therapeutics 2000; 23: 239-45.
Nyiendo J, Haas M, Goodwin P.

Patients with chronic (>6 weeks), recurrent lower back pain were treated by either a chiropractor or a family medicine clinic. After one month of treatment, chiropractic patients averaged higher improvement across all outcome measurements. The differences between provider groups were most marked for the question involving satisfaction with overall care (chiropractic-90%; medical– 52%). Chiropractic patients also reported greater improvement in pain severity and functional disability. This study concluded that chiropractic patients expressed greater satisfaction regarding information and treatment provided.

2000 - Economic Case for the Integration of Chiropractic Services into the Health Care System
J Manipulative Physiol Ther 2000 (Feb); 23 (2): 118–122

In this study the author explores the effects of the integration of chiropractic care into the health care system. The author indicates that greater use of chiropractic care would lead to reduced costs and improved outcomes. As support, the author points to studies which demonstrate that chiropractic is effective for neuromusculoskeletal disorders and the evidence that patients often prefer chiropractic care over a medical approach.