This week from Dr. Cerami and Utah Sports and Wellness

From: Public Library of Science, 2018

Quick Summary:

The aim of this trial was to investigate the effectiveness of chiropractic maintenance care on pain for patients with recurrent or persistent low back pain.  It was an investigator-blinded, randomized controlled trial using 328 subjects aged 18-65 years, with non-specific low back pain, who had an early favorable response to chiropractic care. This study found that patients who used a maintenance style of care  had almost 2 full weeks less of back pain per year than those using a symptom-based program of care, with an average difference of less than 2 more appointments per year for those utilizing a maintenance style of care. The idea behind maintenance care is that maintenance (or asymptomatic) care can improve movement and neuromuscular function. Additionally, it may address psychosocial issues – meaning people are less worried about falling back into pain and are less cautious about their back in their activities of daily living. When it comes to treating chronic low back pain, maintenance care can be a good option for preventing back pain as well as treating it when it does pop up.

Abstract:

To describe and interpret Danish Chiropractors’ perspectives regarding the purpose and rationale for using MC (maintenance care), its content, course and patient characteristics. Semi-structured interviews were conducted with 10 chiropractors identified using a stratified, theoretical sampling framework. Interviews covered four domains relating to MC, namely: purpose, patient characteristics, content, and course and development. Data was analyzed thematically. Practitioners regard MC primarily as a means of providing secondary or tertiary care and they primarily recommend it to patients with a history of recurrence. Initiating MC is often a shared decision between clinician and patient. The core elements of MC are examination and manipulation, but exercise and general lifestyle advice are often included. Typically, treatment intervals lie between 2 and 4 months. Clinician MC practices seem to evolve over time and are informed by individual practice experiences. Chiropractors are more likely to offer MC to patients whose complaints include a significant muscular component. Furthermore, a successful transition to MC appears dependent on correctly matching complaint with management. A positive relationship between chiropractor and patient facilitates the initiation of MC. Finally; MC appears grounded in a patient-oriented approach to care rather than a market-oriented one. MC is perceived as both a secondary and tertiary preventative measure and its practice appears grounded in the tenet of patient-oriented care. A positive personal relationship between chiropractor and patient facilitates the initiation of MC. The results from this and previous studies should be considered in the design of studies of efficacy.

These authors also note:

• “Non-specific low back pain (LBP) is one of the most common and costly healthcare problems in society today.”
• “The burden of disabling low back pain on individuals, families, communities, industries and societies is substantial and is now the leading cause of activity limitation and work absence in the world.”
• Low back pain is often recurrent and has a large negative impact on society.
• Focusing on preventive strategies for recurrent low back pain is logical.
• “For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition.”
• “Chiropractors are trained to assess and treat disorders of the musculoskeletal system, of which LBP is the most common.”
• “The majority of patients seeking chiropractic care receive some form of manual therapy, of which spinal manipulation and mobilization are the most common, often along with advice on exercise.”
• Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies against new episodes of low back pain, or in reducing the impact of a new episode of low back pain. “It is common for chiropractors to recommend maintenance care, i.e. preventive consultations/visits for recurrent and persistent musculoskeletal pain and dysfunction.”
• Maintenance chiropractic care may improve biomechanical and neuromuscular function and address psychosocial issues, thereby reducing the risk of relapse into pain.
• About one fifth of all visits to Scandinavian chiropractors are maintenance care visits and 98% of Swedish chiropractors use the approach to some extent.
• “Chiropractic maintenance care resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment.”
• Results: the chiropractic maintenance care group (n = 163) had 12.8 fewer days in total with bothersome low back pain.
• “The total number of days with bothersome low back pain over the 12 months was 85.2 for the maintenance group and 98.0 for the control group.”
• The maintenance group had a faster reduction in days with bothersome low back pain and reached a lower steady state earlier.
• “No serious adverse events were recorded.”
• Maintenance chiropractic care was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP by about 13 days, but it resulted in a higher number of treatments (by 1.7).
• Maintenance chiropractic care should be considered an option for tertiary prevention of low back pain. 17) Maintenance chiropractic care “resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment.”
• Yet, “the maintenance group required only a slightly higher number of visits [1.7 visits] to the chiropractor than the control group.”
• The maintenance chiropractic care group “improved faster and achieved the steady state phase earlier with a lower mean number of days with LBP per week.”
• “The treatment was not reported as being linked to any serious harm and both the intervention and the control regimes must be considered safe treatments.”
• There were minor transient reactions to the treatment, such as local soreness for 1-2 days.
• “The results of this study support the findings of the only other sufficiently powered RCT to have investigated preventive manual care. They found that patients who continued to receive spinal manipulation after an initial course of care had lower pain and disability scores at a 10-month follow-up.”
• The authors note that the maintenance care in this study was between 1 and 3 months, which may be an inadequate frequency for best outcomes.
• “Some clinicians suggested that some patients (the ones with more persistent pain) would have benefited from shorter intervals than 1 month to be able to prevent future episodes.”

This week from Dr. Cerami and Utah Sports and Wellness

From: Archives of Physical Medicine and Rehabilitation, April 2017 (https://www.archives-pmr.org/article/S0003-9993(17)30262-9/pdf)

Quick Summary:

The objective of this study was to investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain as compared to no treatment. It is a Randomized Controlled Trial (three groups) that involved 225 adults with symptomatic low back pain of 3 months or longer. Within-group disability scores were significantly improved in the Orthotics and Plus Groups after six weeks of care, with an average of 2.3 and 4.3 point improvements in the Orthotics and Plus Groups respectively. The addition of chiropractic care to the orthotic treatment demonstrated better outcomes than orthotic care alone. The best results were in the Orthotics Plus group in which 70% had a decrease in pain and 56% a decrease in disability of 30% or more compared to baseline; followed by 58% and 38% respectively in the Orthotics group, and only 22% and 20% in the Wait-List Control group. This is the first large-scale clinical trial assessing orthotics for treatment of LBP. As hypothesized, LBP and dysfunction were significantly improved with custom-made shoe orthotics compared to a wait-list control group, and disability was more significantly improved with the addition of chiropractic care.

Abstract:

To investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain compared with no treatment. Randomized controlled trial. Integrative medicine teaching clinic at a university. Adult subjects (NZ225) with symptomatic low back pain of !3 months were recruited from a volunteer sample. Subjects were randomized into 1 of 3 treatment groups (shoe orthotic, plus, and waitlist groups). The shoe orthotic group received custom-made shoe orthotics. The plus group received custom-made orthotics plus chiropractic manipulation, hot or cold packs, and manual soft tissue massage. The waitlist group received no care. The primary outcome measures were change in perceived back pain (numerical pain rating scale) and functional health status (Oswestry Disability Index) after 6 weeks of study participation. Outcomes were also assessed after 12 weeks and then after an additional 3, 6, and 12 months. After 6 weeks, all 3 groups demonstrated significant within-group improvement in average back pain, but only the shoe orthotic and plus groups had significant within-group improvement in function. When compared with the waitlist group, the shoe orthotic group demonstrated significantly greater improvements in pain (P<.0001) and function (PZ.0068). The addition of chiropractic to orthotics treatment demonstrated significantly greater improvements in function (PZ.0278) when compared with orthotics alone, but no significant difference in pain (PZ.3431). Group differences at 12 weeks and later were not significant. Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared with no treatment. The addition of chiropractic care led to higher improvements in function.

These authors also note:

• “Low back pain (LBP) is a steadily increasing global epidemic.”
• Approximately 25% of the US adult population experiences LBP during a 3- month time period, and nearly half experience back pain over the course of a year.
• Podiatrists have connected the use of foot orthotics with the relief of low back pain because back pain may be related to a disruption in the kinetic chain.
• A number of studies have linked foot hyperpronation to abnormal pelvic alignment and low back pain.
• “Foot dysfunction should not be overlooked as a potential contributing factor in treating individuals with LBP and dysfunction.”
• “72.1% of chiropractors combine spinal manipulation with custom-made shoe orthotics for the treatment of pain.”
• “When compared to the Wait-list Group, the Orthotics Group demonstrated significantly greater improvements in pain and function.”
• “Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared to no treatment. The addition of chiropractic care led to higher improvements in function.”

This week from Dr. Cerami and Utah Sports and Wellness

From: BoiMed Central (BMC) Health Services Research, October 2015

Quick Summary:

This comprehensive study was designed to compare health care costs for patient with spine pain who received chiropractic care v. care from other health care providers. This review identified 25 cost comparison studies published in English since 1993 that were related to chiropractic care for spine pain in the US. Spine pain is one of the most common and costly causes of health care utilization in the United States, with 61% of patients seeking care from a medical physician (MD or DO), 28% from a chiropractor, and 11 % from both a medical physician and a physical therapist. Chiropractors in the US treat spine pain almost exclusively, with the most common indication for care being low back pain (68%), followed by neck pain (12%), and mid-back pain (6%). Only 3% of office visits to medical physicians are related to spine pain. “Patients with spine pain report higher levels of satisfaction with chiropractic care than care from a medical physician.” Chiropractors may offer a more cost-effective approach to managing spine pain as a consequence of: lower fees for office visits, use of x-rays rather than more advanced diagnostic imaging, lower referral rates to spine specialists or surgeons (implying chiropractors are achieving good clinical outcomes) and reduced need for medications, injections or surgery.

Abstract:

Although chiropractors in the United States (US) have long suggested that their approach to managing spine pain is less costly than other health care providers (HCPs), it is unclear if available evidence supports this premise. A systematic review was conducted using a comprehensive search strategy to uncover studies that compared health care costs for patients with any type of spine pain who received chiropractic care or care from other HCPs. Only studies conducted in the US and published in English between 1993 and 2015 were included. Health care costs were summarized for studies examining: 1. private health plans, 2. workers’ compensation (WC) plans, and 3. clinical outcomes. The quality of studies in the latter group was evaluated using a Consensus on Health Economic Criteria (CHEC) list. The search uncovered 1276 citations and 25 eligible studies, including 12 from private health plans, 6 from WC plans, and 7 that examined clinical outcomes. Chiropractic care was most commonly compared to care from a medical physician, with few details about the care received. Heterogeneity was noted among studies in patient selection, definition of spine pain, scope of costs compared, study duration, and methods to estimate costs. Overall, cost comparison studies from private health plans and WC plans reported that health care costs were lower with chiropractic care. In studies that also examined clinical outcomes, there were few differences in efficacy between groups, and health care costs were higher for those receiving chiropractic care. The effects of adjusting for differences in sociodemographic, clinical, or other factors between study groups were unclear. Although cost comparison studies suggest that health care costs were generally lower among patients whose spine pain was managed with chiropractic care, the studies reviewed had many methodological limitations. Better research is needed to determine if these differences in health care costs were attributable to the type of HCP managing their care.

These authors also note:

• “Spine pain is one of the most common and costly causes of health care utilization in the United States, with 61% of patients seeking care from a medical physician (MD or DO), 28% from  a chiropractor, and 11 % from both a medical physician and a physical therapist.”
  • “In eleven (92%) studies, health care costs were lower for patients whose spine pain was managed with chiropractic care.”
  • “Overall, 11/12 (92%) studies in private health plans reported that health care costs were lower for members whose spine pain was managed by chiropractic care, by a mean of 36%.”
• The authors note that the only study reporting higher health care costs with chiropractic care may be explained as chiropractors billing more but being paid a smaller amount.
• These authors note that it is important to understand that “indirect costs (e.g. lost productivity) account for a majority of the total costs of spine pain, and that they were “generally lower for patients receiving chiropractic care.” [Important, implying that chiropractic care keeps back pain patients working or gets them to return to work more quickly.]
• “In general, the findings in this review suggest that health care costs may be lower when spine pain is managed with chiropractic care in the US, even if such differences are sometimes attributable to sociodemographic, clinical, or other factors rather than healthcare providers.”
• “These findings echo that of a review published in 1993 that examined studies in which LBP was managed by spinal manipulation, chiropractic care, other interventions (e.g. physical modalities, medications, exercise) throughout the world (e.g. Australia, Canada, Egypt, Italy, the Netherlands, New Zealand, Nigeria, Sweden, United Kingdom, and US). Based on the favorable short-term clinical improvements and lower costs of care reported in those studies, the previous review concluded that health care costs could be reduced if a higher proportion of patients with spine pain received chiropractic care rather than other interventions, and recommended a greater integration of chiropractors into the publicly financed health care system in Ontario, Canada.”
  • “However, that recommendation was never implemented, and publicly financed coverage of chiropractic services was subsequently eliminated in Ontario to alleviate budget deficits.”
  • “Other studies have reported similarly favorable clinical or economic results [from chiropractic care] in both Canada (i.e. Calgary, Ottawa) and the US (i.e. Boston).”
• “Overall, cost comparison studies from private health plans and WC plans reported that health care costs were lower with chiropractic care.”
• The “cost comparison studies suggest that health care costs were generally lower among patients whose spine pain was managed with chiropractic care.