Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review.

BACKGROUND: The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain. METHODS: A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators. RESULTS: The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures. CONCLUSION: Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.

Best Practices for Chiropractic Management of Adult Patients With Mechanical Low Back Pain: A Clinical Practice Guideline for Chiropractors in the United States.

OBJECTIVE: The purpose of this paper was to update the previously published 2016 best-practice recommendations for chiropractic management of adults with mechanical low back pain (LBP) in the United States. METHODS: Two experienced health librarians conducted the literature searches for clinical practice guidelines and other relevant literature, and the investigators performed quality assessment of included studies. PubMed was searched from March 2015 to September 2021. A steering committee of 10 experts in chiropractic research, education, and practice used the most current relevant guidelines and publications to update care recommendations. A panel of 69 experts used a modified Delphi process to rate the recommendations. RESULTS: The literature search yielded 14 clinical practice guidelines, 10 systematic reviews, and 5 randomized controlled trials (all high quality). Sixty-nine members of the panel rated 38 recommendations. All but 1 statement achieved consensus in the first round, and the final statement reached consensus in the second round. Recommendations covered the clinical encounter from history, physical examination, and diagnostic considerations through informed consent, co-management, and treatment considerations for patients with mechanical LBP. CONCLUSION: This paper updates a previously published best-practice document for chiropractic management of adults with mechanical LBP.

The Role of Chiropractic Care in Providing Health Promotion and Clinical Preventive Services for Adult Patients with Musculoskeletal Pain: A Clinical Practice Guideline.

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January-February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Federal Employees' Compensation Act and Mandating the Use of X-ray for Chiropractic Management of Federal Employees: An Exploration of Concerns and a Call to Action.

OBJECTIVE: The purpose of this article is to explore concerns regarding sections of the federal workers' compensation law that apply to the treatment and management of work-related injuries of federal employees by chiropractors, and to offer a call to action for change. DISCUSSION: A 1974 amendment to the Federal Employees' Compensation Act (FECA) stipulates that chiropractic services rendered to injured federal workers are reimbursable. However, the only reimbursable chiropractic treatment is "manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist." This means the chiropractor must take radiographs in order to be reimbursed. As with other health care professions, chiropractors are expected to practice according to best practices guided by studies in the scientific literature. Yet in the federal workers' compensation arena, this law requires chiropractors to practice in a manner that is fiscally wasteful, contradicts current radiology standards, and may expose patients to unnecessary X-ray radiation. Presently, there is discord between what the law mandates, chiropractic training and scope, and what professional guidelines recommend. In this article we discuss how FECA creates problems in the following 7 categories: direct harm, indirect harm, contradiction of best practices, ethical dilemma, barriers to conservative treatment, fiscal waste, and discrimination. CONCLUSION: The 1974 FECA provision requiring chiropractors to take radiographs regardless of presenting medical necessity should be updated to reflect current chiropractic education, training, and best practice. To resolve this discrepancy, we suggest that the radiographic requirement and the limitations placed on chiropractic physicians should be removed.

Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline.

Objective: To develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain. Design: CPG based on evidence-based recommendations of a panel of experts in chronic MSK pain management. Methods: Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology. Results: The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized. Conclusions: These evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.

Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain.

OBJECTIVE: The purpose of this study was to develop best-practice recommendations for chiropractic management of adults with neck pain. METHODS: A steering committee of experts in chiropractic practice, education, and research drafted a set of recommendations based on the most current relevant clinical practice guidelines. Additional supportive literature was identified through targeted searches conducted by a health sciences librarian. A national panel of chiropractors representing expertise in practice, research, and teaching rated the recommendations using a modified Delphi process. The consensus process was conducted from August to November 2018. Fifty-six panelists rated the 50 statements and concepts and reached consensus on all statements within 3 rounds. RESULTS: The statements and concepts covered aspects of the clinical encounter, ranging from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral for patients presenting with neck pain. CONCLUSIONS: These best-practice recommendations for chiropractic management of adults with neck pain are based on the best available scientific evidence. For uncomplicated neck pain, including neck pain with headache or radicular symptoms, chiropractic manipulation and multimodal care are recommended.

Clinical Practice Guideline: Chiropractic Care for Low Back Pain.

OBJECTIVE: The purpose of this article is to provide an update of a previously published evidence-based practice guideline on chiropractic management of low back pain. METHODS: This project updated and combined 3 previous guidelines. A systematic review of articles published between October 2009 through February 2014 was conducted to update the literature published since the previous Council on Chiropractic Guidelines and Practice Parameters (CCGPP) guideline was developed. Articles with new relevant information were summarized and provided to the Delphi panel as background information along with the previous CCGPP guidelines. Delphi panelists who served on previous consensus projects and represented a broad sampling of jurisdictions and practice experience related to low back pain management were invited to participate. Thirty-seven panelists participated; 33 were doctors of chiropractic (DCs). In addition, public comment was sought by posting the consensus statements on the CCGPP Web site. The RAND-UCLA methodology was used to reach formal consensus. RESULTS: Consensus was reached after 1 round of revisions, with an additional round conducted to reach consensus on the changes that resulted from the public comment period. Most recommendations made in the original guidelines were unchanged after going through the consensus process. CONCLUSIONS: The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain disorders.

Consensus terminology for stages of care: acute, chronic, recurrent, and wellness.

OBJECTIVE: As the chiropractic profession delineates its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management. Therefore, the Council on Chiropractic Guidelines and Practice Parameters engaged in a multidisciplinary consensus process addressing the terminology related to "levels of care." METHODS: A formal consensus process was conducted in early 2009, following the RAND/UCLA method for rating appropriateness. Panelists were selected to provide a broad representation of the profession in terms of geographic location and organizational affiliation, and an attempt was made to include members of other professions, including representation from third-party payors. The Delphi process was conducted electronically in January-February 2009. A nominal group panel was conducted through an online meeting service using an experienced group facilitator. Twenty-seven panelists were selected; all but 3 were doctors of chiropractic. Six of the panelists had experience as consultants with third-party payors. RESULTS: Fifteen seed statements were circulated to the Delphi panel. Consensus was reached on all statements after 3 Delphi rounds, with further refinements made through the nominal group panel. CONCLUSIONS: By using a recognized formal consensus process, the Council on Chiropractic Guidelines and Practice Parameters has endeavored to establish a set of terms that are acceptable to the chiropractic community in order to facilitate their use within the broader health care community.

Chiropractic management of low back disorders: report from a consensus process.

OBJECTIVE: Although a number of guidelines addressing manipulation, an important component of chiropractic professional care, exist, none to date have incorporated a broad-based consensus of chiropractic research and clinical experts representing mainstream chiropractic practice into a practical document designed to provide standardized parameters of care. The purpose of this project was to develop such a document. METHODS: Development of the document began with seed materials, from which seed statements were distilled. These were circulated electronically to the Delphi panel until consensus was reached, which was considered to be present when there was agreement by at least 80% of the panelists. RESULTS: The panel consisted of 40 clinically experienced doctors of chiropractic, representing 15 chiropractic colleges and 16 states, as well as both the American Chiropractic Association and the International Chiropractic Association. The panel reached 80% consensus of the 27 seed statements after 2 rounds. Specific recommendations regarding treatment frequency and duration, as well as outcome assessment and contraindications for manipulation were agreed upon by the panel. CONCLUSIONS: A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

Resolution of cervical radiculopathy in a woman after chiropractic manipulation.

OBJECTIVE: To describe a case regarding a woman with 2-level cervical disk herniation with radicular symptoms conservatively treated with chiropractic care including high-velocity, low-amplitude (HVLA) manipulation with complete resolution of her symptoms. CLINICAL FEATURES: A 40-year-old woman developed right finger paresthesia and neck pain. Results of electrodiagnostics were normal, but clinical examination revealed subtle findings of cervical radiculopathy. A subsequent magnetic resonance imaging revealed a large right posterolateral disk protrusion and spur impinging on the right hemicord with moderate to severe central canal and right neuroforaminal stenosis at C5-6 and C6-7. She was treated with HVLA manipulation to the cervical spine, as well as soft tissue techniques, traction, nonsteroidal anti-inflammatory drugs, and exercise. INTERVENTION AND OUTCOME: Her clinical findings and symptoms resolved within 90 days of initiating care and did not return in 1 year. There were no untoward effects, including transient ones. CONCLUSION: This case describes the clinical presentation and course of a patient with multilevel large herniated disks and associated radiculopathy who was treated with HVLA manipulation and other conservative approaches and appeared to have good outcomes.