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( Click here to go back to the main "Why Chiropractic?" page )  Today's Health Care Challenges A Condensed Appeal for Chiropractic Care It is clear that the major challenge facing our health care system today is to lower the cost of care without sacrificing its quality. One area that is particularly promising in this regard is the treatment of neuromusculoskeltal disorders by doctors of chiropractic (DCs). The following body of evidence has been compiled to show that chiropractic care has a high rate of patient satisfaction and safety, while actually being more effective and less costly than some traditional medical treatments. Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine (Annals of Internal Medicine – 2002 Volume 136 – Number 3) • Chiropractic is the largest, most regulated, and best recognized of the professions that have traditionally functioned outside of mainstream medical institutions. • Chiropractors are used more often than any other alternative provider group (2), and the satisfaction with chiropractic care is very high. • The approach used in chiropractic training and practice for clinical diagnosis is similar to that of all health care disciplines: a history, physical examination, and specialty-specific assessments. • In 1994, the U.S. Agency for Health Care Policy and Research similarly concluded that spinal manipulation was safe and effective for acute low-back pain. This agency reviewed all clinical trials available at the time and found no other treatment to have stronger evidence. • A recent trial found that manipulation for patients with sciatica related to disc herniation was better than chemonucleolysis. • Chiropractic theory has held that subluxation and manipulation can have important physiologic effects: increased range of joint motion, changes in facet joint kinematics, increased pain tolerance, increased muscle strength, attenuation of motoneuron activity, enhanced proprioceptive behavior, and changes in endorphins and substance P. A biomechanical picture of manipulation is beginning to emerge from studies on the forces involved and the resultant kinetics and kinematics. Patients using Chiropractors in North America - Who Are They, and Why Are They in Chiropractic Care? (SPINE 2002 Volume 27, Number 3) • The proportion of the population using chiropractic services has doubled in the past 20 years.  • Patients were very satisfied with their chiropractic care. The level of satisfaction with chiropractic care was quite high (mean score of 87.4 of 100), a finding that has been consistently demonstrated. Is Chiropractic Evidence Based? A Pilot Study (Journal of Manipulative and Physiological Therapeutics 2003 Volume 26, Number 1) • When compared to the many other studies of similar design that have evaluated the extent to which different medical specialties are evidence based, chiropractic practice was found to have the highest proportion of care (68.3%) supported by good-quality experimental evidence. A Comparative Study of Chiropractic and Medical Education (Alternative Therapies, September 1998, Vol. 4, No. 5) • An intriguing result is that chiropractic education devotes more time to the basic and clinical sciences than does medical education. • In our interviews with medical students, 2 things became clear: (1) these students spend little time studying the neuromusculoskeletal system and its health-related problems, the subjects of most concern to chiropractors, and (2) they receive little or no education in alternative healthcare and no education in chiropractic care. 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 – October 2002, Vol. 92, No. 10) • Studies concluded that patients were more satisfied with chiropractic care than with physical therapy after 6 weeks. • Results from observational studies suggest that back pain patients are more satisfied with chiropractic care than with medical care. Chronic Spinal Pain - A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation (SPINE 2003 Volume 28, Number 14) • The consistency of the results provides evidence that in patients with chronic spinal pain, manipulation results in greater short-term improvement than acupuncture or medication. • In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results. Patterns and Perceptions of Care for Treatment of Back and Neck Pain - Results of a National Survey (SPINE 2003 Volume 28, Number 3) Chiropractic, massage, and relaxation techniques were rated as "very helpful" for back or neck pain among users (61%, 65%, and 43%, respectively), whereas conventional providers were rated as "very helpful" by 27% of users. Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain (Annals of Internal Medicine May 2002; 136: 713-722) • At 7 weeks, 68.3% of patients in the manual therapy group reported resolved ot much improved pain, compared with 50.8% of patients in the physical therapy group and 35.9% of patients in the continued care group. • Primary care physicians should consider referrals for manual therapy when treating patients with neck pain. 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 Physiologic Therapeutics May 2000) • Chronic low back patients treated by chiropractors show greater improvement and satisfaction at one month than patients attending family physicians. The Chiropractic Report Card: Patient Satisfaction Study (Journal of the American Chiropractic Association – October 1997) • Patients of 208 practitioners in North Carolina, including primary care physicians, urban chiropractors, rural chiropractors, orthopedic surgeons, and primary care providers of an HMO, were the subject of a study regarding care they received for back pain between June 1992 and March 1993. After six months of treatment, the researchers concluded that patients were most satisfied with the care they received from the chiropractors. By illustration, the article points out that the biggest difference in patient satisfaction with chiropractic care for back pain was in the quality of the doctors' "history taking, examination, and explanation of the problem during the visit." The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain (Richmond Hill, Ontario: Kenilworth Publishing, 1993) • A major study to assess the most appropriate use of available health care resources was reported in 1993 by the Ontario Ministry of Health. The Report overwhelmingly supported the efficacy, safety, scientific validity, and cost-effectiveness of chiropractic for low-back pain. • "There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management ... The evidence includes studies showing lower chiropractic costs for the same diagnosis and episodic need for care." Survey Conducted by Health Benchmarks Reveals High Patient Satisfaction with Chiropractic Treatment (American Specialty Health Members Report, 2003) • A significant number of respondents revealed that they had a medical condition they thought the chiropractor could treat (67%), they had successfully used a chiropractor before (52%), and wanted to avoid taking prescription medications (31%). The Agency for Health Care Policy and Research On December 8, 1994, The Agency for Health Care Policy and Research (AHCPR) of the U.S. Department of Health and Human Services, released an extensive study of diagnostic and treatment methods for acute low back pain. The 23-member committee of medical doctors, nurses, chiropractic doctors, experts in spine research, physical therapists, a psychologist, an occupational therapist and a consumer representative -- concluded, among other things, that: • spinal manipulation is a recommended treatment for acute low back problems in adults; • conservative treatment such as manipulation should be pursued -- in most cases -- before surgical interventions are considered; • prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems. The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache. (Journal of Manipulative and Physiological Therapeutics 1997; 20(5): 326-330.) Of 53 individuals who were diagnosed with cervicogenic headaches 28 individuals in the group received high speed, low amplitude spinal manipulation in the cervical spine two times a week for three weeks. The rest of the group received low level laser to the upper cervical region and deep friction massage in the lower cervical/ upper thoracic region two times a week for three weeks. For those who received spinal manipulation treatment the amount of headache hours per day decreased 69%, while for those receiving laser treatment the decrease was only 37%. Intensity of headache decreased 36% for those receiving manipulations and 17% for those receiving laser treatment. The use of pain relievers went down 36% for those receiving manipulations and was unchanged for those receiving laser treatment. Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial. (Journal of Manipulative and Physiological Therapeutics 1995; 18(3): 148-154.) This study compared the effects of spinal manipulation and pharmaceutical treatments for chronic tension headaches. Four weeks following the cessation of treatment the pharmaceutical group demonstrated no improvement from the baseline. In the spinal manipulation group headache intensity dropped 32% frequency dropped 42% and there was an overall improvement of 16% in functional health status. Chiropractic in the Mainstream Patient Evaluations of Care from Family Physicians and Chiropractors (Western Journal of Medicine, March 1989) • Patients of chiropractors were three times as likely as patients of family physicians to respond that they were satisfied with the care they received for low back pain, the survey showed. Chiropractic patients were also more likely to have been satisfied with the amount of information they were given and to believe their doctor was concerned about them. • This study was conducted at the Group Health Cooperative of Puget Sound, a 40-year-old staff-model health maintenance organization (HMO) in western Washington State with 32,000 enrollees. • The percentage of chiropractor patients who were "very satisfied" with the care they received for low back pain was triple that for patients of family physicians (66% versus 22%). Cost-Effectiveness of Chiropractic Care in a Managed Care Setting (American Journal of Managed Care 1996;2) • In our evaluation, all patients were HMO members who could access care only through participating physicians or chiropractors • Overall costs per patient were $539.33 for the chiropractic group versus $774.06 for the nonchiropractic group(note: 1995 data) • Chiropractic care was substantially more cost-effective than conventional care • The authors conclude that properly managed chiropractic care can yield outcomes, in terms of surgical requirements and patient satisfaction, that are equal to those of non-chiropractic care, at a substantially lower cost per patient. Economic Case for the Integration of Chiropractic Services into the Health Care System (Journal of Manipulative and Physiological Therapeutics, February 2000) • The integration of chiropractic care into the health care system should serve to reduce health care costs, improve accessibility to needed care, and improve health outcomes. The overall conclusions of a recent review were that the vast majority of studies and the methodologically better studies showed that chiropractic costs were significantly lower than medical costs for back problems. • Chiropractic-managed patients reported a higher degree of satisfaction with their care than medically managed patients. New Study Provides Proof of Chiropractic's Cost-Saving Impact on Medicare Program A new study of Medicare cost data completed in June by the well-known Washington, DC-based firm Muse & Associates helps prove the cost-saving impact that chiropractic care has on the current federal Medicare program. The study, titled "Utilization, Costs, and Effects of Chiropractic Care on Medicare Program Costs," is the first study of its type to compare the global, per capita Medicare expenditures of chiropractic patients to those of non-chiropractic patients receiving care in the federal Medicare program. The study utilizes data obtained from Medicare's Standard Analytical Files for 1999--the most recent year cost data is available for analysis. The study specifically found that: • beneficiaries who received chiropractic care had lower average Medicare payments for all Medicare services than those who did not ($4,426 vs. $8,103) • beneficiaries who received chiropractic care averaged fewer Medicare claims per capita than those who did not • beneficiaries who received chiropractic care had lower average Medicare payments per claim than those who did not The report's conclusion suggests that decreased access to chiropractic services would increase the Medicare program's costs. In addition, the report found that, overall, beneficiaries who used chiropractic services had lower medical doctor costs. Due to these cost savings, the report suggests that during any congressional debate on Medicare reform, consideration should be given to providing increased access to chiropractic care. In addition, the study suggests that some savings would probably accrue in the Medicare program if access to chiropractic services were increased in concert with a Medicare prescription drug benefit. The study's executive summary states: "The results strongly suggest that chiropractic care significantly reduces per beneficiary costs to the Medicare program. The results also suggest that Chiropractic services could play a role in reducing costs of Medicare reform and/or a new prescription drug benefit." Florida Paying Too Much For Medical Workers' Comp? Study Reveals Huge Savings If Chiropractic Care More Effectively Used On January 1, 1997, a new Florida Workers' Compensation statute mandated that "medically necessary remedial treatment, care, and attendance be rendered to claimants solely through managed care."1 Chiropractors in Florida became aware that the new policy was greatly restricting their access to workers' compensation claimants. It followed that there were fewer referrals for chiropractic, which led to the supposition that chiropractic's cost-saving impact on job-related musculoskeletal injuries had been greatly diminished. To assess the full impact of the statute on chiropractic, the Florida Chiropractic Association (FCA) contracted a national research firm, to: • trace recent trends in the number of musculoskeletal workers' compensation claims treated by chiropractic before and after Jan. 1, 1997; • assess costs of musculoskeletal claims treated by chiropractic physicians versus those treated by conventional medicine; and • investigate improvements to health care delivery that have resulted form expanded access to chiropractic care in various health care settings.1 The study reviewed the current scientific literature on the cost effectiveness of chiropractic care in workers' compensation, which revealed that substantial cost savings as high as 60 percent can be measured for health care and disability when chiropractic care is applied to low back and other musculoskeletal injuries; that chiropractic care has shown "results in reduced lost-work-time and fewer long-term disabilities." Perhaps the most compelling part of the study was Exhibit 1: SOURCE: Florida Department of Labor and Employment Security, Division of Workers' Compensation, Claims and Medical Billing Data. a Includes contusions, sprains, strains, other specific injuries, other cumulative injuries, and multiple Injuries to the lower back. b Includes contusions, fractures, lacerations, sprains, strains, and other specific injuries to single and multiple parts, excluding single body part injuries to the lower back. c Total injury-specific claims and costs where less than 50% of professional fees were attributed to DCs. d Average injury-specific cost per claim where 50% or more of professional fees were attributed to DCs. e Total cost and savings that result when "non-chiropractic cost per claim" are adjusted to "chiropractic cost per claim." Exhibit 1 demonstrates what the chiropractic profession has been trying to say for decades. Notice that the average cost for low-back cases treated medically is $16,998, while chiropractic care of the case is only $7,309. This places medical costs per claim more than 2.3 times that of chiropractic care for the same types of cases. The study explains the huge differences: "Chiropractic treatment typically involves approximately 80 percent of charges as professional fees, and approximately 20 percent as secondary health costs. This is reversed with conventional medical treatment, approximately 23 percent for physicians' fees, and the remaining 77 percent for the more expensive secondary costs (Chapman-Smith, 2000)."1 The study concluded: "Implications for the Florida workers' compensation system are obvious. Low back pain is responsible for half of workers' compensation costs (Mootz, Franklin, & Stoner 1999). Past research clearly demonstrates the success and cost-effectiveness (inclusive of all direct costs) of chiropractic care compared to other common medical treatments for low back pain. Similar effectiveness and cost savings appear to occur with chiropractic treatment of numerous other work-related musculoskeletal conditions as well. Therefore, the state of Florida should reconsider current policy restricting access of workers' compensation claimants to chiropractic care, and take full advantage of this promising cost containment opportunity."1 Reference : Trends in chiropractic treatment of workers' compensation claimants in the state of Florida. Executive Summary, Feb. 8, 02. MGT of America (www.mgtofamerica.com). Study finds Chiropractic care most cost-effective for Texas worker's compensation claims Last year the Texas Chiropractic Association commissioned an independent study to determine the effectiveness of chiropractic care on workers compensation patients. The national research/consulting firm MGT of America was hired to analyzed about 900,000 workers compensation claims from 1996-2001. Among the firm's findings: • If the nearly 900,000 workers' compensation claims received from 1996 to 2001, only 14.6 percent of claimants were treated by doctors of chiropractic, and only 8.5 percent of those workers received more than half of their treatment from chiropractors. • Chiropractic care accounted for only 12.5 percent of medical fees and 6.9 percent of the total workers' compensation costs. However, the firm noted that these figures did not include the costs of pharmaceuticals, because insurers are not required to provide such information to the Texas Workers' Compensation Commission (TWCC). If those costs were included, the percentage of costs related to chiropractic care would have been even lower. • 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. • 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. If the chiropractor provided at least 90 percent of the care, the average cost declined by more than 50 percent. Based on its analysis, the firm reached two noteworthy conclusions: • Chiropractic's medical costs are the lowest in the state's workers' compensation system. "The existing body of research indicates that chiropractic is a cost-effective means of treatment for musculoskeletal injuries," the firm noted. "Chiropractic care is associated with lower medical costs and more rapid recovery in the overwhelming majority of studies concerning chiropractic care and workers' compensation costs." Data from the study also clearly linked increased use of chiropractic care with lower costs relative to lower back injuries. • Chiropractic cannot be blamed for the state's rising workers' compensation costs. Based on the evidence, the firm found it "unlikely" that chiropractic could be held responsible for escalating costs: "Our analysis of TWCC claims data demonstrated that chiropractic currently plays a relatively small role in the system as a whole, and therefore could not be a significant force in driving costs ... to be a significant factor in driving costs, chiropractic would have to be demonstrated as a vastly more expensive means of treatment, or it would have to comprise a greater share of treatment in this system." Reference: Chiropractic Treatment of Workers' Compensation Claimants in the State of Texas. Submitted to the Texas Chiropractic Association by MGT of America, Austin, Texas, February 2003. The Economic Role of Chiropractic: Further Analysis of Relative Insurance Costs for Low Back Care (Journal of the Neuromusculoskeletal System, Fall 1995) • Payments were nearly twice as great for the medically initiated cases and their outpatient payments were nearly 50% higher. Chiropractic care of Florida workers' compensation claimants: Access, costs, and administrative outcome trends from 1994 to 1999. (Topics in Clinical Chiropractic 2002; 9(4): 33-53.) When examining specific cases involving low back problems if 50% or more of professional fees went to chiropractic care, the patient reached maximum medical improvement 28 days sooner than others. Average lower back claim cost for those visiting chiropractors was $7309, however, for those visiting other providers the figure was nearly double at $16,998. Disabling Low Back Oregon Workers' Compensation Claims. Part II: Time Loss (J Manipulative Physiol Ther 1991 (May); 14 (4): 231–239) For claimants with a history of chronic low back problems, the median time loss days for MD cases was 34.5 days, compared to 9 days for DC cases. It is suggested that chiropractors are better able to manage injured workers with a history of chronic low back problems and to return them more quickly to productive employment. The Risk of NSAID's "Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone. The figures of all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated." Recent Considerations in Nonsteroidal Anti-Inflammatory Drug Gastropathy; The American Journal of Medicine; July 1998 UK Study – 1.9% of NSAID users were admitted to the hospital each year with upper gastrointestinal emergencies. The NSAID attributable emergency admissions in UK is about 12,000 with 2,500 deaths. Study showed for a group of 100,000 people there would be 24 emergency admissions and about five deaths in any one year. Emergency admissions for upper gastrointestinal disease and their relation to NSAID use. Aliment Pharmacol Ther 1997 11(UK) We thus calculated the total number of NSAID-associated hospital admissions for gastrointestinal PUB [Perforations, Ulcers and Bleeding] in the GKV [German statutory health-insurance fund] to be 10,700 per year, necessitating 157,000 hospital days and total costs of DM 125 million. 1,100 to 2,200 fatal cases in the GKV annually were thus expected. Multiplying these figures by a factor of 1.1 provides estimates for the entire German populations." Consequences and Costs of NSAID-Induced Gastropathy in Germany", Akt Rheumotol, 1999, Vol. 24 "During periods of concomitant use of diuretics and NSAIDs, a 2-fold increased risk of hospitalization for CHF [Congestive Heart Failure] was found compared with periods of diuretic used only. Patients with a history of heavy diuretic use showed an increased risk. This may lead to the hypothesis that an existing condition of CHF that is being treated with diuretics is challenged by the introduction of NSAIDs." NSAIDs Associated With Increased Risk of Congestive Heart Failure in Elderly Patients Taking Diuretics." Archives of Internal Medicine, May 25, 1998 " the annual number of hospitalizations in the United States for serious gastrointestinal complications is estimated to be at least 103,000. At an estimated cost of $15,000 to $20,000 per hospitalization, the annual direct costs of such complications exceeds $2 billion." The New England Journal of Medicine, June 17, 1999 "These results led the investigators to suggest that in the United States the syndrome of NSAID-associated gastropathy accounts for at least 2600 deaths and 20,000 hospitalizations each year in patients with rheumatoid arthritis alone." Nonsteroidal Anti-Inflammatory Drugs – Differences and Similarities", The New England Journal of Medicine, June 13, 1991 "Overall death estimates are similarly disquieting. Conservative calculations, counting only excess deaths, indicate that about 7,600 deaths/year in the United States are attributable to NSAID use. The Food and Drug Administration suggests even higher figures, estimating NSAID use accounts for 10,000 to 20,000 deaths/year. These figures are comparable to Hodgkin's disease or acquired immunodeficiency syndrome and represent a serious problem." NSAID Gastropathy: The Second Most Deadly Rheumatic Disease? Epidemiology and Risk Appraisal", Journal of Rheumatology, 1991, (Supplement 28)    ( Click here to go back to the main "Why Chiropractic?" page )