Roger Wilhelm, D.C.

The primary reason (93%) patients go to chiropractors is for the management of spinal pain (1). Specifically, 63% go to chiropractors for low back pain, and 30% due so for neck pain. The effectiveness of chiropractic care for spinal pain is well-documented. Chiropractic care (spinal manipulation) is routinely included in spine pain clinical practice guidelines (2, 3, 4, 5, 6, 7).

The focus of this presentation is to review published studies that assess the cost effectiveness of chiropractic care for musculoskeletal pain syndromes, primarily for back and neck pain complaints.

•••

In 2004, a 4-year study compared health care expenditures of 700,000 health plan members who had a chiropractic benefit with 1 million members of the same plan without the same benefit. The study was published in the journal Archives of Internal Medicine, titled (8):

Comparative Analysis of Individuals with and Without Chiropractic: Characteristics, Utilization, and Costs

The authors concluded that systematic access to managed chiropractic care lowers overall health care costs and results in improved clinical outcomes.

•••

Also, in 2004, a study was published in the Journal of Occupational Environmental Medicine, titled (9):

Chiropractic Care:
Is it Substitution Care or Add-on Care in Corporate Medical Plans?

The authors found that chiropractic care was primarily used as a substitution for other types of medical care that is often less effective and costlier. The authors concluded that chiropractic care “lowers cost when compared with treatment from traditional medical providers.”

•••

In 2009, researchers from Mercer Health and Benefits and Harvard Medical School published a paper titled (10):

 Do Chiropractic Physician Services for Treatment of Low-back
and Neck Pain Improve the Value of Health Benefit Plans?

An Evidence-based Assessment of Incremental Impact
on Population Health and Total Health Care Spending

The authors noted:

• The annual cost for treatment of neck pain by chiropractors was lower than treatment from medical physicians.
• “When considering effectiveness and cost together, chiropractic  physician care for low back pain and neck pain is highly cost-effective and represents a good value in comparison to medical physician care.”

• “Our findings in combination with existing U.S. studies published in peer-reviewed scientific journals suggest that chiropractic-delivered care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefit plans.”
• “Both value and clinical outcomes show marked improvement with the addition of chiropractic coverage for the treatment of low back and neck pain in US employer-sponsored health benefit plans.”

•••

In 2010, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (11):

Cost of Care for Common Back Pain Conditions Initiated with
Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician:

Experience of One Tennessee-based General Health Insurer

The authors examined a fully BlueCross/BlueShield insured population of 85,000 subscribers over a 2-year period. Their findings included:

• “Patients who experience low back pain and seek treatment first from a chiropractor rather than an MD/DO save 40% on average of health care-related costs.”
• For BlueCross/BlueShield of Tennessee, chiropractic-initiated episodes of care could lead to an annual cost savings of approximately $2.3 million.
• “Insurance companies may be inadvertently paying more for care with restricted access to chiropractic-initiated care than if such restrictions were removed.”

•••

Also, in 2010, a study was published in the Spine Journal, titled (12):

The Chiropractic Hospital-Based Interventions
Research Outcomes (CHIRO) Study:
A Randomized Controlled Trial on the Effectiveness of
Clinical Practice Guidelines in the Medical and
Chiropractic Management of Patients
with Acute Mechanical Low Back Pain

The authors noted that chiropractor-delivered spinal manipulations were very effective for low back pain compared to usual care administered by primary care medical doctors.

•••

In 2013, a study was published in the journal Spine, titled (13):

Early Predictors of Lumbar Surgery After Occupational Back Injury:
Results from a Prospective Study of Workers in Washington State

The authors showed that spine surgeries can be avoided through chiropractic care. Specifically, the odds of surgery for those who first saw a chiropractor were only 1.4%, while the odds for those who first saw a surgeon were 42.7%.

•••

In 2014, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (14):

Cost-effectiveness of Manual Therapy
for the Management of Musculoskeletal Conditions:
A Systematic Review and Narrative Synthesis
of Evidence from Randomized Controlled Trials

The authors found:

• Chiropractic-delivered manipulation is less costly than physiotherapy or general practitioner care.
• “Manual therapy techniques are more cost-effective for low back and shoulder pain and disability than care delivered by general practitioners (GPs) alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management.”
• Chiropractic-delivered manipulations are less costly and more effective for neck pain than the alternatives.
• “Evidence showed manual therapy to be economically advantageous compared with other treatments of musculoskeletal conditions.”
• “Chiropractic-delivered therapy is equally effective and more cost-efficient than usual medical care.”

•••

In 2015, a study was published in the journal Spine, titled (15):

Comparison of Spinal Manipulation Methods
and Usual Medical Care for Acute and Sub-acute Low Back Pain:
A Randomized Clinical Trial

The authors found:

• Of patients receiving chiropractic manipulation, 94% had a 30% reduction in low back pain after 4 weeks, while only 56% of medical care recipients had the same reduction.
• “This suggests a 38% increase in effectiveness by seeing a DC first.”

•••

In 2019, a study was published in the Journal of Chiropractic Humanities, titled (16):

Cost-Efficiency and Effectiveness of Including
Doctors of Chiropractic to Offer Treatment Under Medicaid:
A Critical Appraisal of Missouri Inclusion
of Chiropractic Under Missouri Medicaid

This article is an in-depth appraisal of the cost effectiveness for the inclusion of chiropractic services under Missouri Medicaid. The article includes extensive mathematical analysis determining the value of chiropractic healthcare. This article proposes that chiropractors deliver care that is more effective and less costly than the current model.

These authors suggest that when the Missouri Health Division initially assessed the value of Chiropractic, for the Missouri Medicaid program, for the management of neck and low back pain, that their scoring approach was (“unintentionally”) flawed, and as such they undervalued the fiscal benefits of chiropractic. Hence, these authors re-evaluated the value of chiropractic for the Missouri Medicaid program using improved assumptions.

These authors assessed 3 cost saving values attributed to chiropractic care:

• Cost savings from chiropractic care v. traditional MD/DO care
• Cost savings from reductions in spinal surgery
• Cost savings from reduced use and abuse of opioid prescription drugs

The distribution of providers for spine care in the United States shows that chiropractic care is second, accounting for more than a quarter of all cases:

• 61% Medical Doctor and/or Doctor of Osteopathy (MD/DO)
• 28% Doctor of Chiropractic (DC)
• 11% from a combination of providers

The authors make these points:

• “Spine pain is a pervasive health care problem in the United States.”
• “There is an 80% chance that people will have back pain at some point in their lives.”
• “In the U.S., neck pain is one of the top musculoskeletal disorders in the adult population.”
• The fourth most pervasive reason for disability globally is neck pain.
• “Between 1990 and 2010, the U.S. had a 29% increase in neck pain.”
• “More U.S. adults have chronic pain (headache, neck or back pain, arthritis, or joint pain) than heart disease, diabetes, and cancer combined.”
• “Chiropractic-delivered services for back and neck pain are significantly more cost-effective when compared with all alternative approaches.”
• “The benefits of care provided by doctors of chiropractic (DCs) have been demonstrated by research throughout the U.S. health care system.”
• “Although there are potentially numerous beneficial clinical outcomes from DC treatment, perhaps the greatest clinical outcome is the reduction of neck and low back pain.”

The authors note that seeing a chiropractor does not increase overall healthcare spending. They report:

• Overall medical spending is not increased from seeking care from a chiropractor.
• “Hospitalization expenditures were significantly lower for those who used complementary and alternative providers, including chiropractic.”
• Chiropractor-delivered spinal manipulations are very effective for low back pain compared to usual care administered by primary care MDs.

The authors also understand that an important but often under-appreciated benefit of chiropractic care is its potential to reduce the costly and dangerous incidence of spinal surgery as well as reducing the use of opioid drugs. The authors make these points:

• “Research shows that chiropractors are the safest and most effective alternative to surgery for most cases of back pain.”
• “60% of patients with sciatica benefited from spinal manipulation after attempting medical management and failing to experience any improvement.”
• Chiropractic treatment “leads to 60% reduction in spinal surgery.”
• “In light of the research showing that chiropractic-managed care can reduce the incidence of spinal surgery, it is reasonable to suppose that a number of surgeries could be avoided through routine chiropractic management.”
• “One fact is sure, patients in the Missouri Medicaid system would benefit from the avoidance of spinal surgeries, and this would lead to significant cost savings for the state.”
• “Chiropractors treat low back and neck pain without resorting to the prescription of opioids or any other type of drugs.”

A summary of the important findings from this study includes:

• The Missouri Health Division had used increasingly flawed assumptions and methodologies over the past years in their cost estimates pertaining to chiropractic care, resulting in flawed conclusions pertaining to chiropractic care.
• Current research on the cost-effectiveness of chiropractic-delivered care compared to usual medical care reveals: “People with insurance coverage that includes chiropractic had lower annual health care costs”; “Those who seek chiropractic-guided treatment first saved an average of 40% on annual health care costs”; “Seeking treatment from a chiropractor did not add to overall medical spending”; “Chiropractic-directed treatment led to a 60% decrease in spinal surgeries”; “Chiropractic-directed care was 38% less costly than usual medical care”; “Chiropractic-delivered care lowered costs and increased positiveoutcomes.”
• “Too often, people who seek relief from lower back pain through usual medical care end up taking painkillers, which are addictive and lead to negative outcomes.”
• “Patients who visit DCs not only find relief from neck and lower back pain at lower annual cost, but also they report their outcomes to be more effective.”
• “Chiropractic care leads to cost savings from reduced use and abuse of opioid prescription drugs.”
• “There are now a dozen states that have embraced alternative therapies such as DC care to combat the cost of the opioid abuse epidemic.”
• “This study supports the proposition that treatment by DCs for neck and lower back pain may reduce the use and abuse of opioid prescription drugs.”
• “Chiropractic treatment and care leads to a reduction in cost of spinal surgery.”

•••

In 2021, a study was published in the Journal Spine, titled (17):

Longitudinal Care Patterns and Utilization Among Patients
with New-Onset Neck Pain by Initial Provider Specialty

The authors were from the University of California, Davis; Yale University School of Medicine; and Harvard Medical School. This study was a retrospective cohort design involving 777,326 patients, aged 18 to 89 years. Its objective was to compare utilization patterns for patients with new-onset neck pain by initial provider specialty. All patients had new-onset neck pain.

This study was the first evaluation of a national sample of the care patterns of patients with acute neck pain with classifications by initial provider specialty. Provider specialties included:

• Chiropractor
• Primary care, including family practice and internal medicine
• Emergency medicine
• Orthopedics
• Physical therapy/occupational therapy (PT/OT)
• Neurology
• Rehabilitation medicine

The authors noted that “neck pain is the fourth most common cause of disability worldwide, resulting in substantial activity limitation, work time lost, and associated costs.”

In this analysis, chiropractic care was the most often healthcare provider seen for patients with new-onset neck pain. The specific breakdown was as follows:

• Chiropractor 45%
• Primary Care 33%
• Emergency Medicine 8%
• Orthopedic Surgeon 5%
• Physical/occupational Therapist 3%
• Neurologist 3%
• Rehabilitation Medicine 3%

The authors state:

• “Within this large national cohort, chiropractors were the initial provider for a plurality of patients with new-onset neck pain.”
• “The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%).”
• In patients initially seen by orthopedists: 6.8% received therapeutic injections; 3.4%received major surgery
• In patients initially seen by chiropractors: 0.4% received therapeutic injections; 0.1% received major surgery

This indicates that patients who initially saw a chiropractor for their neck pain were 40% less likely to have injections compared to patients who initially saw an orthopedic surgeon. Patients who initially saw a chiropractor for their neck pain were 97% less likely to have major surgery compared to patients who initially saw an orthopedic surgeon.

Also, these authors note that patients seeing chiropractors were significantly less likely to use expensive advanced imaging, particularly CT and MRI. The authors state:

• Patients initially seen by chiropractors “received fewer and lower-intensity imaging studies, perhaps because these providers prioritize physical diagnosis and immediate therapeutic intervention.”

 The authors concluded:

• “Within this large, national cohort of patients with new-onset neck pain, we found that chiropractors were the initial provider for a plurality of patients and that patients with chiropractor or PT/OT initial providers received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions, such as injection or major surgery, during follow-up.”
• “Starting with a chiropractor was associated with lower rates of invasive therapeutic interventions and surgery, our study suggests initial care for new-onset neck pain by chiropractors is likely associated with lower longer-term care intensity and costs.”
• “Our findings raise the question whether more frequent referrals from physicians to chiropractors or PT/OTs might enhance the efficiency of care for patients with new-onset neck pain.”
• “Health systems may also seek means of engendering more frequent referrals from primary care or specialist physicians to chiropractors for patients with new-onset neck pain.”

•••

In 2024, a study was published in the journal Chiropractic & Manual Therapies, titled (18):

Cost of Chiropractic Versus Medical Management of Adults
with Spine-related Musculoskeletal Pain:
A Systematic Review

The purpose of this study was to update, summarize, and evaluate the evidence for the cost of chiropractic care compared to conventional medical care for management of spine-related musculoskeletal pain. The literature search used 44 studies (26 cohort studies, 17 cost studies, and 1 randomized controlled trial).

The authors note that “spine-related musculoskeletal pain is the leading cause of disability worldwide and one of the most common reasons for missed work.” In the U.S., chiropractic care is one of the most commonly utilized approaches to treatment of spine-related musculoskeletal pain.

In this review, no studies found that chiropractic care had higher overall costs. No studies found higher long-term healthcare costs in those using chiropractic care. Specifically, these authors found:

 Fifteen studies found that diagnostic imaging, particularly advanced imaging like MRI, was used less with DC care.

• Eleven studies found that fewer opioid prescriptions were dispensed or filled with DC care.
• Eight studies found fewer surgeries with DC care.
• Seven studies found fewer hospitalizations with DC care.
• Six studies analyzed cost factors related to having a DC as the 1st care provider, and generally, this was associated with lower downstream costs.
• Five studies found decreased use of injection procedures with DC care.
• Five studies found fewer referrals for specialist visits with DC care.
• Two studies found that fewer ED visits were associated with DC care.

These authors state:

“This study adds further confidence in the emerging body of evidence on provider-related cost differentials and provides a compelling case for the influence of conservative care providers as the first provider managing for spine-related musculoskeletal pain.”

“Diagnostic imaging, opioid utilization, surgery, hospitalizations, injection procedures, specialist visits, and emergency department visits were all reduced where chiropractors were involved early in the case.”

“When considering this evidence, it may be in society’s best interest for U.S. healthcare organizations and governmental agencies to consider modifying benefit designs to reduce barriers to access chiropractic providers.”

“Eliminating these barriers (preauthorization requirements, medical doctor gatekeepers, arbitrary visit limits, co-pays, and deductibles) would allow  easier access to chiropractic services, which based on currently available  evidence consistently demonstrates reduced downstream services and  associated costs.”

“Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management.”

“The recurrent theme of the data seems to support the utilization of chiropractors as the initial provider for an episode of spine-related musculoskeletal pain.”

“Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals, and injection procedures.”

•••

Summary

For decades, the best evidence has found that chiropractic care is both effective and safe for the management of spinal pain syndromes. The evidence presented in this publication also shows that chiropractic care is exceptionally cost-effective as well. This adds to the position that chiropractic care should be the “go-to” provider for spine pain syndromes.

REFERENCES

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Chou R; Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK; Diagnosis and Treatment of Low Back Pain; Annals of Internal Medicine; Vol. 147; No. 7; October 2007; pp. 478-491.
3. Chou R, Huffman LH, MS; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007; Vol. 147; No. 7; pp. 492-504.
4. Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, DC, Whalen WM, Walters S, Kaeser M, Dehen M, DC, Augat T; Clinical Practice Guideline: Chiropractic Care for Low Back Pain; Journal of Manipulative and Physiological Therapeutics; January 2016; Vol. 39; No. 1; pp. 1-22.
5. Intentionally left blank.
6. Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A; Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration; European Journal of Pain; Vol. 21; No. 2 (February); 2017; pp. 201-216.
7. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians; For the Clinical Guidelines Committee of the American College of Physicians; Annals of Internal Medicine; April 4, 2017; Vol. 166; No. 7; pp. 514-530.
8. Legorreta A, Metz D, Nelson S, Ray H, Chernicoff O, DiNubile N; Comparative analysis of individuals with and without chiropractic: characteristics, utilization, and costs; Archives of Internal Medicine; October 11, 2004; Vol. 164; No. 18; pp. 1985-1992.
9. Metz R, Nelson C, LaBrot T, Pelletier K; Chiropractic care: is it substitution care or add-on care in corporate medical plans? Journal of Occupational Environmental Medicine; August 2004; Vol. 46; No. 8; pp. 847–855.
10. Choudhry N, Milstein A; Do chiropractic physician services for treatment of low-back and neck pain improve the value of health benefit plans? An evidence-based assessment of incremental impact on population health and total health care spending; Mercer Health and Benefits; 2009.
11. Liliedahl R, Finch M, Axene D, Goertz CM; Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer; Journal of Manipulative and Physiological Therapeutics; Nov-Dec 2010; Vol. 33; No. 9; pp. 640–643.
12. Bishop P, Quon J, Fisher C, Dvorak M; The chiropractic hospital-based interventions research outcomes (CHIRO) study: A randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain; Spine Journal; December 2010; Vol. 10; No. 12; pp. 1055–1064.
13. Keeney B, Fulton-Kehoe D, Turner J, Wickizer T, Chan K, Franklin G; Early predictors of lumbar surgery after occupational back injury: Results from a prospective study of workers in Washington State; Spine; May 15, 2013; Vol. 38; No. 11; pp. 953–964.
14. Tsertsvadze A, Clar C, Court R, Clarke A, Mistry H, Sutcliffe P; Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials; Journal of Manipulative and Physiological Therapeutics; Jul-Aug 2014; Vol. 37; No. 6; pp. 343–362.
15. Schneider M, Hass M, Glick R, Stevans J, Landsittel D; Comparison of spinal manipulation methods and usual medical care for acute and sub-acute low back pain: A randomized clinical trial; Spine; February 15, 2015; Vol. 40; No. 4; pp. 209–217.
16. McGowan JR, Suiter L; Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid: A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid; Journal of Chiropractic Humanities; December 2019; Vol. 10; No. 26; pp. 31-52.
17. Fenton JJ, MD, Fang SY, Ray M, Kennedy J, Padilla K, Amundson R, Elton D, Haldeman S, Lisi AJ, DC, Jason Sico S, MD, MHS, Peter M. Wayne PM, Romano PS; Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty; Spine; October 15, 2023; Vol. 48; No 20; pp. 1409–1418.
18. Farabaugh R, Hawk C, Taylor D, Daniels C, Noll C, Schneider M, McGowan J, Whalen W, Wilcox R, Sarnat R, Suiter L, Whedon J; Cost of Chiropractic Versus Medical Management of Adults with Spine-related Musculoskeletal Pain: A Systematic Review; Chiropractic & Manual Therapies; March 6, 2024; Vol. 32; No. 1; Article 8.

“Authored by Dan Murphy, D.C. Published by ChiroTrust^® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”