Sunday, 30 April 2017 11:55

Chiropractic Care is More Effective in Lowering Disability than Medical Care for Acute and Sub-Acute Low Back Pain

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Chiropractic Care is More Effective in Lowering Disability than Medical Care for Acute and Sub-Acute Low Back Pain

 

By Mark Studin DC, FASBE(C), DAAPM, DAAMLP

William J. Owens DC, DAAMLP

A report on the scientific literature

 

By any standard, back pain is one of the most prevalent disabilities plaguing our population. According to Block, 2014, over 100 million Americans experience chronic pain with common painful conditions including back pain, neck pain, headaches/migraines, and arthritis, in addition to other painful conditions such as diabetic peripheral neuropathy, etc... In a large study in 2010, 30.7% of over 27,000 U.S. respondents reported an experience of chronic, recurrent pain of at least a 6-month duration. Half of the respondents with chronic pain noted daily symptoms, with 32% characterizing their pain as severe (≥7 on a scale ranging from 0 to 10). Chronic pain has a broad impact on emotional well-being and health-related quality of life, sleep quality, and social/recreational function. (pg. 1)

 

According to Schneider et al., 2015 “low back pain is among the most common medical elements an important public health issue. Approximately 50% of the United States working – age adults experience low back pain each year with a quarter of US adults reported in episode back pain in the previous three months. Back pain is the most common cause of disability for persons younger than 45 years old and one of the most common reasons for office visits to primary care physicians in the United States as well as Europe and Australia.” (pg. 2009)

 

In chiropractic, although chiropractic’s scope is significantly beyond back pain, based upon the sheer volume of low back pain sufferers, there simply aren’t enough chiropractors to manage this “epidemic sized” condition. In addition, chiropractors as a profession do not want to be labeled as solely “low back pain doctors.” Although the authors firmly agree, we also must acknowledge while treating mechanical spine pain (no fracture, tumor or infection) that the formal health care system has fallen short and in its effort, has contributed to the opiate epidemic.  Healthcare in the United States has had a myopic focus on “anatomical” sources of spine pain such as herniated disc and degenerative disc disease while ignoring the impact that faulty biomechanics have on spine pain and disability.  When it comes to the biomechanics of the spine, it is the responsibility of the chiropractic profession, based upon training and outcomes to lead the nation in its diagnosis, management and treatment.  When we consider both anatomical and biomechanical spine conditions are significant contributors to the spine pain and disability epidemic in the United States, we must understand its full impact and the standard healthcare system’s (allopathic) inability to manage the biomechanical side. 

 

Block, 2014 continued “In addition to the pervasive personal suffering associated with this disease, chronic pain (author’s note: where low back pain is one of the most significant contributors) has a substantial negative financial impact on the economy. Direct office visits, diagnostic testing, hospital care, and pharmacy costs are only a portion of the picture, with combined medical and pharmacy costs averaging $5,000 annually per individual. Chronic pain results in a significant economic burden on the healthcare system, with estimated costs ranging from $560 to $635 billion 2010 dollars, more than the annual cost of other priority health conditions including cardiovascular disease, cancer, and diabetes. Moreover, the estimated annual costs of the workplace impact of pain range from $299 to $335 billion from absenteeism and reduced productivity.” (pgs. 1-2) These statistics help us to understand that “management” of spine pain is a critical component of cost reduction since the costliest portion of healthcare services is when a patient enters the system.  Continued mismanagement of mechanical spine pain causes patients to move in and out of disability status. That reentry is what drives up cost, chiropractic is the 3rd largest health profession in the United States and the largest with the education to lead the diagnosis and management of mechanical spine pain.

 

When we compare who is better educated to manage mechanical back pain cases, we also must conclude as a result, who is better educated to successfully treat those cases based upon outcomes. In this comparison, we will consider the education of chiropractic vs. traditional musculoskeletal education and competency as well as treatment outcomes.

 

In a recent article written by Humphreys, Sulkowski, McIntyre, Kasiban, and Patrick (2007), they stated, “In the United States, approximately 10% to 25% of all visits to primary care medical doctors are for MSK [musculoskeletal] complaints, making it one of the most common reasons for consulting a physician...Specifically, it has been estimated that less than 5% of the undergraduate and graduate medical curriculum in the United States and 2.26% in Canadian medical schools is devoted to MSK medicine” (p. 44).

 

Musculoskeletal complaints have a major impact on the healthcare system and although many patients believe that traditional providers are highly trained, recent publications relating to basic competency have shown otherwise.  For example, the authors cited another study stating, Humphreys et al., 2007 continues by stating, “A study by Childs et alon the physical therapists’ knowledge in managing MSK conditions found that only 21% of students working on their master’s degree in physical therapy and 25% of students working on their doctorate degree in physical therapy achieved a passing mark on the BCE [Basic Competency Evaluation]” (p. 45). 

The authors continued by reporting, “The objective of this study was to examine the cognitive (knowledge) competency of final-year chiropractic students in MSK [musculoskeletal] medicine" (p. 45).  "The typical chiropractic curriculum consists of 4,800 hours of education composed of courses in the biological sciences (i.e., anatomy, embryology, histology, microbiology, pathology, laboratory diagnosis, biochemistry, nutrition, and psychology), chiropractic sciences, and clinical sciences (i.e., clinical diagnosis, neurodiagnostic, ortho-rheumatology, radiology, and psychology).  As the diagnosis, treatment, and management of MSK disorders are the primary focus of the undergraduate curriculum as well as future clinical practice, it seems logical that chiropractic graduates should possess competence in basic MSK medicine” (Humphreys et al., 2007, p. 45).

The following results were published in this paper for the Basic Competency Examination and various professions that are in the front line of the diagnosis and treatment of musculoskeletal conditions.  In Table 2 on page 47, the following results were shown when the passing score was established at 73% or greater:

Recent medical graduates (18%), medical students, residents, and staff physicians (20.7%), osteopathic students (29.6%) physical therapy (MSc level, 21%), physical therapy (doctorate level, 26%), chiropractic students (51.5%). 

In Table 2 on page 47, the following results were show when the passing score was established at 70% or greater. 

Recent medical graduates (22%), medical students, residents, and staff physicians (NA), osteopathic students (33%) physical therapy (MSc level, NA), physical therapy (doctorate level, NA), chiropractic students (64.7%). 

According to Frank Zolli DC, former Dean at the University of Bridgeport, College of Chiropractic, “Fundamental to the training of doctors of chiropractic is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and students receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctor of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. It is so important to practice these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education, requires a curriculum which enables students to be proficient in neuromusculoskeletal evaluation, treatment and management. In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE) in 4 separate parts including clinical evaluations. It is therefore mandatory for a chiropractor to know the structure and function of the human body,  the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education.” As a result, the doctor of chiropractic has an expertise in the diagnosis and management of biomechanical musculoskeletal disorders that the traditional health care system is lacking. Chiropractic offers significant insight where traditional health care has no answers.

 

When it comes to direct influence of the chiropractic adjustment on spine pain patients, a 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind why people with severe muscle spasms in the low back respond well to chiropractic care which in turn is shown to prevent future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. This study renders evidence that chiropractic spinal adjusting provides a direct nervous system and physiologic response to the human body. 

 

In a recently published case study and literature review in the New England Journal of Medicine, Deyo and Mirza (2016) had published a case study and literature review on the diagnosis and treatment of lumbar disc herniation with sciatica. What is useful in this publication is the review of the literature in basic, easy to use format highlighting the most common treatments associated in lumbar disc herniation with sciatica.  

Regarding the chiropractic adjustment, the authors stated “A randomized trial of chiropractic manipulation for sub-acute or chronic “back-related leg pain” (without confirmation of nerve-root compression on MRI) showed that manipulation [author’s note: Chiropractic spinal adjustment]  was more effective than home exercise with respect to pain relief at 12 weeks (by a mean 1-point decrease on a pain-intensity scale on which scores ranged from 0 to 10, with higher scores indicating greater severity of pain) but not at 1 year. This is important since early intervention of chiropractic care will reduce early dependency on pain medication. In addition, a randomized trial involving patients who had acute sciatica with MRI-confirmed disk protrusion showed that at 6 months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulation (55% vs. 20%).  Neurologic complications in the lumbar spine, including worsened disk herniation or the cauda equina syndrome, have been reported anecdotally, but they appear to be extremely rare.” (pg 1768) 

In relationship to counseling versus supervised exercise, the authors reported,“A systematic review of five randomized trials showed that patients who participated in supervised exercise had greater short-term pain relief than patients who received counseling alone, but this reduction in pain was small and these patients did not have a long-term benefit with respect to reduced pain or disability.” (pg. 1768) 

Concerning oral steroids, the paper reported, “Randomized trials show no significant advantage of systemic glucocorticoid (steroid) therapy over placebo with respect to pain relief or reduced rates of subsequent surgical intervention, and they show little, if any, advantage with respect to improvement in physical function.” (pg. 1767) 

The authors commented on opioid medication by stating,“Data from randomized trials to support the use of opioids in patients with sciatica are lacking.   Systematic reviews suggest that opioids have slight short-term benefits with respect to reduced back pain.  Convincing evidence of benefits of long-term use is lacking, and there is growing concern regarding serious long-term adverse effects such as fractures and opioid overdose and abuse.” (pg. 1767) 

Focusing on spinal injection therapy the paper continues by reporting, “A systematic review showed that patients with radiculopathy who received epidural glucocorticoid injections had slightly better pain relief (by 7.5 points on a 100-point scale) and functional improvement at 2 weeks than patients who received placebo. There were no significant advantages at later follow-up and no effect on long-term rates of surgery.” (pg. 1768)

This report serves as a nice general guideline for the primary care [conservative] management of lumbar disc herniation with sciatica.  We see that in addition to any anatomical correction there is a positive response to biomechanical interventions for which the properly trained and credentialed chiropractor is an important provider.  

Cifuentes et al., 2011 stated, “Given that chiropractors are proponents of health maintenance care, we hypothesize that patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because this specific approach would be used.Conversely, similar patients treated by other providers would have higher recurrence rates because the general approach did not include maintaining health, which is a key component to prevent recurrence” (Cifuentes, Willetts, & Wasiak, 2011, p. 396). 

This research is unique and comprehensive in that it tracked injured workers’ compensation patients in multiple states and it reviewed claims dated between January 1, 2006 and December 31, 2006 including 894 cases out of a pool of 11,420 claims of non-specific low back pain cases.  (The states were chosen because the patients had the ability to select their doctors on their own and were not mandated a provider.)   

Relating to the results, the authors report, “In our study, after controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors. Care from chiropractors during the disability episode (“curative”), during the health maintenance period (main exposure variable, “preventative”), and the combination of both (curative and preventive) was associated with lower disability recurrence HRs” (p. 403). This article validates chiropractic's role in the prevention of the recurrence of back pain in patients with chronic spine disorders.  

When analyzing why, the reasons are evident and based upon the literature. A chiropractic spinal adjustment reduces verifiable bio-neuro-mechanical failures (commonly known as vertebral subluxation in our profession) at the spinal level.  Non-steroidal anti-inflammatory drugs do not and there is no “spontaneous recovery,” only less pain with the underlying biomechanical failures persisting awaiting Wollf’s law to adversely remodel the spine leading to certain increased permanent disability over time. Therefore, if “literature based outcomes” “ruled the day” (as they should in a reasonable world void of politics and financial interest) at the legislative and reimbursement levels, then we would be a healthier society and spend far less money while avoiding unnecessary side effects and increasing the potential for significantly greater disabilities in the future.

 

References:

  1. Block, C. K. (2014). Examining neuropsychological sequelae of chronic pain and the effect of immediate-release oral opioid analgesics (Order No. 3591607). Available from ProQuest Dissertations & Theses Global. (1433965816). Retrieved from http://search.proquest.com/docview/1433965816?accountid=1416
  1. Humphreys, B. K., Sulkowski, A., McIntyre, K., Kasiban, M., & Patrick, A. N. (2007). An examination of musculoskeletal cognitive competency in chiropractic interns. Journal of Manipulative and Physiological Therapeutics, 30(1), 44-49.
  2. Deyo, R. A., & Mirza, S. K. (2016). Herniated Lumbar Intervertebral Disk. New England Journal of Medicine, 374(18), 1763-1772.
  3. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
  1. Schmale, G. A. (2005). More evidence of educational inadequacies in musculoskeletal medicine. Clinical Orthopaedics and Related Research, 437, 251-259.
  2. DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study. Journal of Manipulative and Physiologic Therapeutics, 28(7), 465-471.
  3. Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L., Hamilton, L., Avins, A. L. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: A randomized clinical trial.Journal of the American Medical Association (JAMA), 313(19), 1915-1923.

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