Chiropractic

Primary Spine Care

A mandatory “future trend” for chiropractic success that has already begun

By Mark Studin

William J. Owens

Primary Spine Care has been proven in the market place as chiropractic’s future and the instrument to increase our utilization. Primary Spine Care simply means that the chiropractor is the first referral option for mechanical spine issues short of fracture, tumor or infection. After 10 years of development and 4 years of market testing, this paradigm has been released nationally and has far exceeded our expectations based upon the dramatic increased utilization of chiropractic services nationwide from private practice to hospitals.   If you are committed to being “the best-of-the-best” through clinical excellence, you can still create a leadership position in your community for both you and your practice with not losing sight that this is happening, with you or without you, and if you are not out in front you will potentially be forever behind. 

Insurers are scrambling to “corner the market” using the lure of primary spine care.  In the end, this is just another plan to further limit your reimbursements; it is “managed care in sheep’s clothing”. Hospitals are also devising primary spine care schemes to dupe you into becoming one of their devoted “minions” into a 1-way referral pattern; with you referring into THIER system while avoiding referring into YOURS. Chiropractic academia is also struggling to catch the primary spine care trend, while their true mandate is to prepare our future doctors of chiropractic to pass national and state boards.  Our politicians and political organizations have realized they are also significantly behind this trend and are reaching “inward” in a hope for someone within the organization to try to take a leadership position. Although our political organizations are vocally touting their ability to grow chiropractic, we can see historically the opposite is true.  Our profession has thought leading with politics was the answer and that path would finally deliver chiropractic into the mainstream, however, based upon published evidence, that approach has proven to deliver relatively stagnant growth as reported by Adams et. Al (2017).  Adams states chiropractic utilization to be 8.4% of the population. It was also reported that 35.2% of the United States population takes over the counter drugs and 23.2% takes prescription medications for the same conditions that respond favorably to chiropractic care. The disparity in utilization of drugs vs. chiropractic care underscores that our global approach to the promotion of chiropractic care is failing, and it can no longer be “business as usual.”

One of the fastest growing trends in healthcare today, is defining who should be considered a “Primary Spine Care Practitioner.” There is a myriad of factors to consider and the timing, based upon a “Best Practice/Evidence Based  Models” (consisting of the scientific literature, patient feedback/expectations and the doctors experience) is perfect for chiropractic to take its place as the leading profession in this critically important niche.  As a society, we are failing to provide adequate spine care.  One of the issues that inevitably occurs when there is a trend catching everyone’s attention, is the rise of the “fly by night, get rich quick, self-proclaimed gurus” that cut corners behind the scenes, but gives you the perception that they are true leaders.  Our profession has a significant history of this occurring, particularly in the managed care arena and we are seeing it starting to happen within the contemporary Primary Spine Care Practitioner trend.  We wanted to provide insight on what is occurring from our unique position, which combines both chiropractic and medical academia and clinical practice.  We would like to outline the critical factors to consider so you can prepare to effectively participate and leverage this important trend in healthcare to your private practice.  The end result; increase utilization (you are busier).

The following should be considered a guide to your path to success in Primary Spine Care and WHO to participate WITH and WHO to AVOID.

TRACK RECORD OF SUCCESS

One of the most important aspects of evaluating a Primary Spine Care training program, or even taking advice at the academic, political or consulting end is determining whether the program and its instructors are coming from a position of success.  Do they present with a proven track record or are they are simply capturing a trend and experimenting with you and your practice?  Consider the reality television show The Shark Tank, a show which has billionaire investors investigating companies that want them to invest in their products or services. The Sharks have a simple rule, which is an underlying theme of the show, what has the “wannabe” business PRODUCED in revenue or success PRIOR to a Shark considering investing their personal money? If the answer is little or none, then the Shark passes since speculation rarely leads to profit. Too many Primary Spine Care “guru’s” promote a pathway to success, but have not achieved any significant level of expertise or track record in filling offices in a profitable scenario. These are the groups that have so called “friends” on the inside and at first glance seems impressive, but as you dig deeper into their past successes they come up empty.  It is important to not enter a training program that needs YOU to grow, that is a recipe for failure, frustration and no return on your investment.  We suggest asking how many chiropractors are currently in the program and how may referrals they have to date in their system [most do not keep track for obvious reasons] and GET references.  Facts are facts and not rhetoric and no matter how “sexy” a program appears, it means nothing if it doesn’t work.  This is the difference between an experimental process and a real program achieving real results.  Don’t be the experiment.

CHIROPRACTIC FIRST

Secondly, we want to caution you to make sure every Primary Spine Care program is putting chiropractic first.  We suggest asking if the program is chiropractic centric or does it concurrently invite physical therapists as Co-Primary Spine Care Providers?  It has long been discussed and demonstrated [CLICK HERE FOR VERIFICATION] that the scientific literature has concluded that chiropractic care for spine is superior to that of physical therapy at many levels including pain management and in the reduction of recurrent disability. 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) reported:

The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation. These differences raise concerns regarding the useof physiotherapists as gatekeepers for the worker’s compensation system. (pg. 388)

Programs that include physical therapy are brining chiropractic down to a level that will not ensure your success as the outcomes are far less effective than a chiropractic spinal adjustment as evidenced in the paragraph above. Physical therapy has its place in spine care, but not first. It is our experience that a program who offers both chiropractic and physical therapy as primary spine care will do this to ensure the profit of the program and NOT YOU. We also firmly believe this creates a public healthcare risk by supporting poorer outcomes, which feed the current opiate epidemic by mismanaging mechanical spine patients. In the end, this will create a perception that chiropractic and physical therapy are equal.  Nothing could be farther from the truth and nothing could be more dangerous to the public and your long-term success.  Only consider a Primary Spine Care program that is chiropractic only.

MANAGED CARE IN DISGUISE

This is one of the most negative aspects of the current Primary Spine Care trend and one that we see happening more and more each week. There are groups in our profession that are promoting the Primary Spine Care concept not to help chiropractic, but to “sell” chiropractic to insurance carriers or hospitals under the umbrella of third party administrators or managed care. This type of focus is NOT in the best interest of chiropractic and does not have your practice’s best interests in mind or the chiropractic profession (for verification, see all the current managed care models that allow 8 or 10 visits at a severely reduced fee, where most have chiropractors controlling your practice and paycheck).  Insurance carriers are not ignorant, they realize the benefits of using chiropractic care and coverage is expanding in these plans, however there are those in our profession that continue to insert themselves between hardworking chiropractors and the insurance carriers.  This is a veiled attempt to create a “network” of doctors that they can sell to the highest bidder.  These “middle men” even promise doctors in their group a steady stream of patients, but in the end, it is an empty promise or worse… you get a lot of patients at such a reduced rate that paying your bills is challenging.  Don’t let this happen to you and your practice. Enriching others at the expense of your practice and your family is not a recipe for success.  We suggest reviewing ALL the directors of ALL programs you are considering and if there is ANY indication that they had consulted with insurance carriers, worked for managed care companies or are significant players in the independent examination world…RUN.  Many are now getting astute and realizing that chiropractors have been taken advantage of for too long, so they leave these things off their CV or Resume.  We suggest searching GOOGLE and Social Media, many have digital trail and an employment track record that can be uncovered.  This is occurring faster and more obviously than previously thought…don’t be taken advantage of, consider WHY the program was created and to whom the money flows. 

HOSPITAL ILLUSIONS

One of the more “sexy” portions of working as a Primary Spine Care Provider is the hospital component.  Since doctors of chiropractic have historically worked outside of the mainstream health system, it continues to be relatively rare for DCs to be included in hospital groups.  Fortunately, hospitals are working with doctors of chiropractic more than ever before, however many of the chiropractors that are leading the way are simply being taken advantage of by the system.  Most chiropractors don’t know it is occurring, while hospitals are “selling” YOU on perceived success in breaking into their system.  In the end, it is just a house of cards and will do nothing to move you or your practice forward.  When working with the hospitals as a Primary Spine Care Provider, the point is that THEY REFER TO YOU as the first option for mechanical spine issues. If the hospital is excited to receive referrals FROM you instead of referring TO you…RUN.  Hospitals not referring to chiropractic as a first choice for spine is NOT a Primary Spine Care Program, it is an enrichment program for the hospital and the consultant that is promoting or selling the program.  Caveat Emptor!!! Do your homework first and do not fall into the trap of being put on a list, having access to doctors in the hospital and having an open line of communication with doctors you refer to… you already have that! A true Primary Spine Care Program ALREADY has established, or will give you the pathway for referrals INTO YOUR office.   Anything other than that is to suck you into the hospital system to get your referrals. Never lose sight that chiropractic is big business for many hospitals and they will do anything to get your business and not give an inch to allow you a piece of theirs. The tide is turning with many hospitals bringing chiropractic on staff, changing by-laws to create chiropractic inclusion into their system and realizing that the best business model is the chiropractor as the first referral option and keep everything else in-house.   Make sure you are creating or entering the right system, a REAL Primary Spine Care Program will teach you that and show you how it has been done in other areas of the country.

ACADEMIC AND CLINCIAL BASIS

In the chiropractic world, there are two places that a program can evolve FROM and two places that it is governed BY.  The program can evolve FROM either an Academic or a Clinical perspective and it can be governed BY either Academics or Politics.  These are very important points to consider.  First, when a program is buried in Academics, although it may be perceived as having state of the art information, it is often built and run from predominantly a theoretical perspective.  This is a prime example of a “it looks good on paper” program, which has not had any real measure of clinical success in the marketplace.  Secondly, when a program is developed and run by clinicians there is often a narrow-sited approach that is missing what the literature provides and not understanding the trends in the industry.  Many times, the clinicians are lacking significant post-graduate training on MRI, Spinal Biomechanical Engineering and triage protocols which ultimately will make the program ineffective or focus on one aspect too heavily. This is at the expense and ultimately the success of your practice. Another alarming trend is when politics drives the process. It is our observation over the last 4 decades that politics typically drives patients and income to those who are in control of the political process and their “friends.” Typically, the rest of the profession, no matter how hard they try, work or get better, simply can’t participate as the system has been designed for so few. In addition, politics in our profession has been controlling too much and has crossed the lines too often in our academic process; they should support academia, not lead it . The “politics first” approach has lead us to an 8.4% utilization in the United States when failing spine care is epidemic nationally and with so many patients suffering, all chiropractic offices should be on a waiting list.

When we consider how a program is governed, the options are either academia or politics and as stated above, politics should support academia, not drive it and the success of a Primary Spine Care program is a perfect example. Politics cannot drive it, there must be a mix of significant post-doctoral (graduate level) formal training and a long history of success in this paradigm.

It can no longer be business as usual, your success and future depend on it.

THE SOLUTION

The perfect solution is a blend of meaningful post-doctoral (graduate level) formal training and clinical practice with a track record of success. Politics as previously stated is there to support the process, not drive the process.  Historically the old way of doing things is not working based upon the 8.4% of our current utilization. Investigate the qualifications and experience of who you are listening to and who you choose to follow, and a blend of academia and successful clinical experiences is the perfect solution. This can be verified by demanding to inspect the Curriculum Vitae of all involved and then scour both Google and social media as previously suggested.     

After 10 years of researching the infrastructure of primary spine care and 4 years of market testing in figuring out HOW to make it work in every chiropractic office in the world, we have ALREADY gotten 711,434 (as of 1-26-2018) referrals INTO chiropractic practices in 47 states from lawyers, primary care medical providers, medical specialists, urgent care centers and emergency room. I also want to report, that this number is an approximate, where the actual number is significantly higher, but that is all we can safely verify. It is this number that would make the “Sharks” happy because it already works, and YOU are not the market research or the EXPERIMENT. It was done with your clinical excellence, a best practice model inclusive of the literature and a business plan that includes medical primary care providers, medical specialists, urgent care centers, hospital emergency rooms and lawyers.

Right now, you are still at the beginning of this “Wave” [or future trend] and you do not have to change how you treat your patients, how you adjust or whether you believe in subluxation or purely a pain model. All you HAVE to do is work within your lawful scope of practice as set forth by your state and get smarter with a business plan to educate your referral sources, so THEY RUN AFTER YOU. Truthfully, that is the easiest part.

References:

  1. Adams, J., Peng, W., Cramer, H., Sundberg, T., Moore, C., Amorin-Woods, L., & Lauche, R. (2017). The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey. Spine42(23), 1810-1816.
  2. Studin M., Owens W. (2016) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320
  3. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392.
 

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Professor at Cleveland University-Kansas City College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a Graduate Medical Clinical Presenter for the State of New York at Buffalo, Jacobs School of Medicine for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it.">This email address is being protected from spambots. You need JavaScript enabled to view it. or at 631-786-4253. 

 

Dr. Bill Owens is presently in private practice in Buffalo NY and generates the majority of his new patient referrals directly from the primary care medical community.  He is an Associate Adjunct Professor at the State University of New York at Buffalo Jacobs School of Medicine, an Adjunct Professor at Cleveland University-Kansas City College of Chiropractic, an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College.  He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. or www.mdreferralprogram.com or 716-228-3847  

 

Share this

Submit to DeliciousSubmit to DiggSubmit to FacebookSubmit to Google BookmarksSubmit to StumbleuponSubmit to TechnoratiSubmit to TwitterSubmit to LinkedIn

Chiropractic Verified as

 Primary Spine Care Providers

By Mark Studin

William J. Owens

A report on the scientific literature 

 

Primary Spine care simply means being the first referral option for spine care in instances other than fracture, tumor or infection. Having a chiropractic degree is paramount and the first step in the process, but one must not forget that any doctoral training, no matter the specialty (i.e. medicine, dentistry, podiatry, etc.) is the start of a provider’s educational journey and what we do with that training is up to the doctor in clinical practice. Erwin, Korpela and Jones (2013) stated “The function of the PSCP (Primary Spine Care Provider) could easily be assumed by chiropractic, but this window of opportunity may be limited. If chiropractic does not seek to evolve, what role does chiropractic have left to perform.” (Pg. 289)

 

Although these authors agree that chiropractors in clinical practice can assume the role as PSCP’s in the healthcare system, we strongly disagree with the direction suggested by Erwin, Korpela and Jones. The solution is not to prescribe more drugs in an “already over-drugged society,” the solution is being able to manage the patient in a collaborative environment on a peer level being “expert” on common healthcare issues. The underlying tenant is that there is no drug for a mechanical problem, it is with that initial focus that allows chiropractic to assume a role that no other profession can accomplish.  True PSCP management includes being able to accurately diagnose/triage patients and the ability to use and understand MRI is a prime example. Herzog, Elgart, Flanders and Moley (2017) reported a 43.6% error rate of general radiologists inaccurately reporting the morphology of the intervertebral disc. This underscores that when a doctor of chiropractic relies on the MRI report without understanding how to interpret the image and clinically correlate the findings to the patient’s symptoms, there is close to a 50% error rate in rendering an accurate diagnosis, prognosis and treatment plan.  A PSCP must have a complete and independent diagnostic scope of practice in order to fill a useful and clinically significant role.

 

To use an example in a current and modern setting, a doctor of chiropractic in Cedar Park, Texas was granted a “brief 10-minutes” to meet with an orthopedic surgeon. During that short meeting the chiropractor, an 8-year graduate spoke solely and specifically of his MRI slice thickness protocols and his MRI interpretation training which is cross-credentialed in both chiropractic and medical academia. One hour later [the meeting continued well past the initial “10-minutes” suggested], the orthopedic surgeon said, “I respect chiropractic, but have very little respect for the level of training of chiropractors in our region.” This 8-year graduate walked out with 8 referrals instantly and now 1 year later, has been getting referrals weekly. That is very definition of Primary Spine Care, the orthopedic surgeon trusts the chiropractor’s ability to manage and diagnose patients and now is “off-loading” the non-surgical patients to someone that can effectively manage that case.  It is because of this specific advanced training that the chiropractor is successful.

 

In a second recent example, in Utah, a chiropractor decided that his post-doctoral training should be focused on spinal trauma care and triage, including more specifically, MRI Spine Interpretation, Spinal Trauma Pathology, Spinal Biomechanical Engineering and Stroke Evaluation. As a result, a hospital system that has over 900 auto accident cases monthly in 5 local hospitals reached out to him to manage their spine cases (all of them).  This was based purely on his curriculum vitae and the inherent credentials and knowledge base from his continued education training in the above courses. Since then, Brigham Young University’s Athletic Department and the PGA (Professional Golf Association) have both sought his services. Please don’t overlook the fact THEY ran after him to be their first option for spine; that is Primary Spine Care and credentials matter.

 

 

Thirdly, in Buffalo NY, 5 teaching hospitals refer exclusively to one chiropractor’s office and their emergency rooms refers close to 60 spine patients per month to him with that number growing steadily. This past week, the neurosurgical department just informed this doctor that their 23 neurosurgeons will be referring their non-surgical cases to this office and will be directing many of their referral sources to START with this doctor to screen for surgery and let him decide who to refer for surgical consultation. That is Primary Spine Care.

 

 

Although individual reporting does not make a trend in the profession, these are not isolated cases, and this is NOW THE TREND in chiropractic we are seeing nationally, there are similar stories in most states. None of the successes involve adding drugs as a tool of the chiropractic, however in every case becoming smarter in spine care was mandatory.  In all cases it is a properly trained doctor of chiropractic that is leading Primary Spine Care alongside medical specialty and primary care in a collaborative environment as peers, when clinically indicated. 

 

 

Most of the Primary Spine Care “equation” is verifying chiropractic care as the “best choice” for the “first referral”.  That is being achieved though peer-reviewed outcome based studies and involves all phases of care starting with initial pain management to corrective spine care and finally when required, health maintenance care for cases that need non-opioid and non-surgical long-term management. Historically and all too frequently in current medicine, either medical management or physical therapy is considered for mechanical spine issues as the first treatment of choice. Cleveland Clinic, one of the better-known centers of medical excellence currently posted the following regarding the treatment of back pain; “These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated.” (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/) The Mayo Clinic Staff (2017) also reported: “Physical therapy is the cornerstone of back pain treatment.”

 

When considering the best option for Primary Spine Care, we should consider “what” type of provider renders the best outcomes in population based studies and has the autonomy to manage the case independent of primary care and medical specialty.   Based upon population based studies, both the Cleveland and Mayo clinics got it wrong as their opinions are not based upon contemporary literature and appear to be rooted in “age-old biases.”  Their suggested care paths are similar to prior care paths that perhaps have led to the long-term mismanagement of mechanical spine pain that has in part, contributed to the opioid crisis.  

 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation.” (pg.392) and These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)

 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care… We did not retrieve any study that directly compared physiotherapy care with other types of first healthcare providers in the context of occupational back pain, probably because most workers’ compensation systems still require a referral for physiotherapy. However, a study comparing primary physiotherapy care with usual emergency department care concluded that physiotherapy care leads to a prolonged time before patients return to their usual activities.” (pg. 389)

 

Cifuentes, Willets and Wasiak (2011) stated that chiropractic care during the health maintenance care period resulted in: 

The study concluded that chiropractic care during the disability episode resulted in:

24% Decrease in disability duration of first episode compared to physical therapy

250% Decrease in disability duration of first episode compared to medical physician's care

5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care

30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care

32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

 

Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating,“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP (low back pain) who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type(pg. 404). 

The above studies continue to verify chiropractic as a better “first option” for spine and that resolves the “what provider is best” question by using an Evidence Based approach.  The “who is best” within that subset is what type of chiropractor is better suited to lead in Primary Spine Care is evident. As an example, although every medical doctor is licensed to do open heart surgery not all are trained and credentialed. Would you want a psychiatrist performing the procedure? The answer should be “they are licensed, but not qualified through training.” The same holds true for contemporary chiropractic and every chiropractor has the same opportunity. We are all held to a “continuing education standard” and are all required to seek post-doctoral training to maintain our licenses. There are a significant number of courses, both live and through enduring materials (online) to enable every chiropractor on the planet to attain the level of education mandated by the “referral sources” to be considered Primary Spine Care Providers. 

Let’s not be Pollyannaish not to think that chiropractic can be successful in increasing utilization independent of the medical community and even the legal community for personal injury cases. As mentioned previously, the medical community DOES NOT CARE about your treatment approach, what they do care about is the “risk” of you missing a diagnosis.  They need to trust you based on your training, and the do NOT care about what technique you use.  What you do in your offices is up to you just like a pain management MD or a surgeon, remember, it’s how you triage and manage your patients that is the ultimate arbiter in having them consider you as the first option for spine care. Once you have responsibly secured the referral, based upon your clinical excellence, you get to independently decide the best course of care for your patient.  Then it is business as usual during the treatment phase of care because results were never, and are not an issue in chiropractic. 

REFERENCES:

 

  1. Erwin, W. M., Korpela, A. P., & Jones, R. C. (2013). Chiropractors as primary spine care providers: precedents and essential measures. The Journal of the Canadian Chiropractic Association, 57(4), 285.
  2. Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal, 17(4), 554-561.
  3. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/
  4. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from:http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797
  5. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392.
  6. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404.

Share this

Submit to DeliciousSubmit to DiggSubmit to FacebookSubmit to Google BookmarksSubmit to StumbleuponSubmit to TechnoratiSubmit to TwitterSubmit to LinkedIn
Published in Neck Problems

The Mechanism of the Chiropractic

Spinal Adjustment/Manipulation:

Chiropractic vs. Physical Therapy for Spine

 

Part 5 of a 5 Part Series

By: Mark Studin

William J. Owens

 

 

Reference: Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, American Chiropractor 39 (12) pgs. 20, 22, 24, 26, 28, 30, 31

 

A report on the scientific literature  

 

According to the Cleveland Clinic (2017):

 

The Cleveland Clinic Spine Care Path is a process-based tool designed for integration in the electronic medical record (EMR) to guide clinical work flow and help providers make evidence-based guidelines operational. 

 

The care path was developed by Cleveland Clinic’s Center for Spine Health with input from Department of Pain Management staff like Dr. Berenger. One goal was to match appropriate treatments and providers to patients at various points along the care continuum for low back pain.

 

We know acute back pain is common and often resolves with simple therapy or even no therapy,” Dr. Berenger says. “For patients without red flags, imaging is rarely required.” 

 

These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated. (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/)

According to the Mayo Clinic Staff (2017):

 

Most acute back pain gets better with a few weeks of home treatment. Over-the-counter pain relievers and the use of heat or ice might be all you need. Bed rest isn't recommended. 

 

Continue your activities as much as you can tolerate. Try light activity, such as walking and activities of daily living. Stop activity that increases pain, but don't avoid activity out of fear of pain. If home treatments aren't working after several weeks, your doctor might suggest stronger medications or other therapies. (http://www.mayoclinic. org/diseases-conditions/back-pain/basics/treatment/con-20020797

 

The Mayo Clinic Staff (2017) continued:

 

Physical therapy is the cornerstone of back pain treatment. A physical therapist can apply a variety of treatments, such as heat, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain.As pain improves, the therapist can teach you exercises that can increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques can help prevent pain from returning. (http://www. mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797)

 

The above 2 scenarios are consistent with contemporary care paths for medicine regarding back pain. High velocity-low amplitude chiropractic spinal adjustments are not part of any medical institution’s care plan (to the current knowledge of the authors) despite the following compelling literature.

Coronado et al. (2012) reported:

 

Reductions in pain sensitivity, or hypoalgesia, following SMT [defined by the author as high velocity-low amplitude adjustment or a spinal adjustment] may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain. (p. 752)

 

Coronado et al. (2012) further asked the question:

 

…was whether SMT [defined by the author as high velocity-low amplitude or a spinal adjustment] elicits a general response on pain sensitivity or whether the response is specific to the area where SMT is applied. For example, changes in pain sensitivity over the cervical facets following a cervical spine SMT would indicate a local and specific effect while changes in pain sensitivity in the lumbar facets following a cervical spine SMT would suggest a general effect. We observed a favorable change for increased PPT [pressure pain threshold] when measured at remote anatomical sites and a similar, but non-significant change at local anatomical sites. These findings lend support to a possible general effect of SMT beyond the effect expected at the local region of SMT application. (p. 762)

Reed, Pickar, Sozio, and Long (2014) reported:

 

…forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems. 

 

Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)

 

With regards to manual therapy versus physical therapy, this is where the phrase, “caveat emperor” should be used as the concept is misleading. Groeneweg et al. (2017) compared manual and physical therapies, recruiting 17 manual therapists and 27 physical therapists. The training of the manual therapists was from Manual Therapy University and were predominantly physical therapists who spent 3 years studying manual therapy. 

Groeneweg et al. (2017) reported:

 

The manual therapist performs per protocol repeated passive joint movements with low velocity and intensity and high accuracy in different positions of the patient (sitting, supine and side-lying). The rhythm of the movements is slow (approximately 30 cycles/min) and the movements are repeated about six times. Treatment is in general painless. Passive joint movements are performed in a combination of rolling and sliding, or rocking and gliding (or swinging and sliding) in the joint, based on the arthrokinematic and osteokinematic principles of intra-articular movements. Passive movements are performed over the entire range of motion within the physiological range of motion of joints, whereby the curvature of the articular surface is followed, with manual forces directed to the joints/specific spinal level. Physiological joint range of motion is carefully respected. Traction, oscillation and high-velocity movements are not applied. In all patients, based on the assessment protocols, all joints of the spine, pelvis and extremities are mobilized in specific directions. (p. 3)

Groeneweg et al. (2017) also stated:

 

This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)

 

The above article strongly confirms why language is important when describing the chiropractic spinal adjustment. Too many “lump together” all manual therapies and claim the effectiveness, or lack thereof, based on studies as the one above confirms. The article compared physical therapy to physical therapists who have gone for advanced education in what they already do in low-amplitude repetitive movements using “arthrokinematic and osteokinematic principles of intra-articular movements” meaning very specific per the anatomy. The outcome confirmed there is no difference between manual therapy and physical therapy because they are the same according to the description in the research. However, these therapies do not provide what chiropractic offers, although many hastily consider manual therapy and chiropractic care to be the same. Substance P is perhaps the most compelling evidence of why a chiropractic spinal adjustment should be considered the “first choice” for spinal care.

Evans (2002) reported:

 

In a series of studies, Brennan et al. investigated the effect of spinal HVLAT manipulation causing cavitation ("sufficient to produce an auditory release or palpable joint movement") on cells of the immune system. They found that a single manipulation to either the thoracic or lumbar spine resulted in a short-term priming of polymorphonuclear neutrophils to respond to an in vitro particulate challenge with an enhanced respiratory burst (RB) as measured by chemiluminescence in subjects with and without symptoms. The enhanced RB was accompanied by a two-fold rise in plasma levels of the neuropeptide substance P (SP).

 

SP is an 11-amino acid polypeptide and is one of a group of neuropeptides known as tachykinins. These are peptides that are produced in the dorsal root ganglion (DRG)  and released by the slow-conducting, unmyelinated C-polymodal nociceptors in a process known as an "axon reflex." They are released into peripheral tissues from the peripheral terminals of the C-fibers. modulating the inflammatory process by "neurogenic inflammation.” They are also released from the central terminals of the nociceptors into the dorsal horn of the spinal cord, where they modulate pain processing and spinal cord reflex activity.

 

This neurophysiologic effect of spinal HVLAT manipulation seems to be force threshold-dependent. The threshold was found to lie somewhere between 450N and 500N for the thoracic spine and 400N for the lumbar spine. When compared with data from biomechanical studies of spinal manipulation, these forces would be sufficient to cause cavitation. The "SP" studies used "sham manipulation" as a control, consisting of a "low-velocity light-force thrust to the selected segment." rather like a mobilization. This illustrates that zygapophyseal HVLAT manipulations that cause cavitation produce physiological effects, not demonstrable by electromyography, that are totally different fi-om effects created by zygapophyseal manipulations that do not cause cavitation. (p. 255-256)

According to Hartford-Wright, Lewis, Vink and Ghabriel (2014):

 

Substance P (SP) is a neuropeptide released from the endings of sensory nerve fibers and preferentially binds to the NK1 receptor. It has a widespread distribution throughout the nervous system, where it is implicated in a variety of functions including neurogenic inflammation, nausea, depression and pain transmission as well as in a number of neurological diseases, including CNS tumors. (p. 85)

Low velocity manipulation, no matter how well it follows “arthrokinematic and osteokinematic principles of intra-articular movements,” will not effectuate the release of Substance P, only a chiropractic spinal adjustment with cavitation will do that. When considering the results of a chiropractic spinal adjustment, disability is a critical indicator with regards to the effectiveness of treatment outcomes.

Cifuentes, Willets and Wasiak (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy is significant.

 

The Cifuentes, Willets and Wasiak (2011) study concluded that chiropractic care during the health maintenance care period resulted in:

The study concluded that chiropractic care during the disability episode resulted in:

24% Decrease in disability duration of first episode compared to physical therapy

250% Decrease in disability duration of first episode compared to medical physician's care

5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care

30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care

32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

 

Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).

 

Given that physical therapy has been the primary portal for mechanical spine issues (not fractures, tumors or infection) coupled with the contemporary opiate addiction and mortality issues, a different path must be sought as a matter of public safety. The only avenue for both medical primary care providers and specialists other than surgery is pain management in the form of opiates and that doesn’t resolve any issues, it only creates new addiction issues. Mechanical spine pain is one of the most common diagnoses.

 

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. (p. 1)

 

Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).

 

 

Mafi, McCarthy and Davis (2013) stated:

 

Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)

 

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.

 

 

Chiropractic offers an evidence-based approach in developing an “outcome based “care path for mechanical spine pain. Although this article discusses pain, chiropractic offers more than simply pain management, however this discussion is limited to mechanical spine pain. Therefore, with chiropractic as the “first option” or “Primary Spine Care” focusing on the biomechanical pathological instability, the underlying cause of the pain can be addressed, leaving no further need to manage an issue that has been simply fixed.

 

 

References

1. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/

2. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from: http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797

3. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. Journal of Electromyography Kinesiology, 22(5), 752-767.

4. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons. Journal of Manipulative and Physiological Therapeutics, 37(5), 277-286.

5. Groeneweg, R., van Assen, L., Kropman, H., Leopold, H., Mulder, J., Smits-Engelsman, B. C., ... & van Tulder, M. W. (2017). Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. Chiropractic & Manual Therapies25(12), 1-12.

6. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.

7. Harford-Wright, E., Lewis, K. M., Vink, R., & Ghabriel, M. N. (2014). Evaluating the role of substance P in the growth of brain tumors. Neuroscience261, 85-94.

8. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404.

9. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine173(17), 1573-1581.

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at www.teachchiros.com or at 631-786-4253.

 

 

Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community.  He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College.  He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at www.mdreferralprogram.com or 716-228-3847  

 

 

Share this

Submit to DeliciousSubmit to DiggSubmit to FacebookSubmit to Google BookmarksSubmit to StumbleuponSubmit to TechnoratiSubmit to TwitterSubmit to LinkedIn
Published in Neck Problems