The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back-Pain

The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce health care costs.

The area of low-back pain (LBP) offers governments and the private sector an excellent opportunity to attain the twin goals of greater cost-effectiveness and a major reduction in health care costs. Today LBP has become one of the most costly causes of illness and disability in Canada.

Much of the treatment of LBP appears to be inefficient. Evidence from Canada, the USA, the UK and elsewhere shows that there are conflicting methods of treatment, that many of these have little if any scientific evidence of effectiveness, that costs of treatment are very high but despite this, levels of disability from LBP are increasing.

In the Province of Ontario LBP is managed mostly by physicians and chiropractors, with physiotherapists also playing a significant role. While medical services are fully insured under Medicare, chiropractic care services are only partially covered. LBP patients incur the highest out-of-pocket expenses for chiropractic services. Virtually no out-of-pocket expenses are incurred for medical treatment, with the exception of drugs, and out-of-pocket expenses incurred for physiotherapy services fall somewhere in between the two.

Physicians, chiropractors, physiotherapists and an assortment of other professionals together offer about thirty-six therapeutic modalities for the treatment of LBP. In this study we focused principally on the effectiveness and cost-effectiveness of chiropractic and medical management of LBP.

F1. On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP. Many medical therapies are of questionable validity or are clearly inadequate.
F2. There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation in unsafe in the treatment of low-back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic complications for LBP patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low-back pain.
F3. Several existing medical therapies of LBP are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by non-chiropractic professionals.
F4. There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management. We reviewed numerous studies that range from very persuasive to convincing in support of this conclusion. The lack of any convincing argument or evidence to the contrary must be noted and is significant to us in forming our conclusions and recommendations. The evidence includes studies showing lower chiropractic costs for the same diagnosis and episodic need for care.
F5. There would be highly significant cost savings if more management of LBP was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually. The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, much fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability. Workers’ compensation studies report that injured workers with the same specific diagnosis of LBP returned to work much sooner when treated by chiropractors than by physicians. This leads to very significant reductions in direct in indirect costs.
F6. There is good empirical evidence that patients are very satisfied with chiropractic management of LBP and considerably less satisfied with physician management. Patient satisfaction is an important health outcome indicator and adds further weight to the clinical and health economic results favouring chiropractic management of LBP.
F7. Despite official medical disapproval and economic disincentive to patients (higher private out-of-pocket cost), the use of chiropractic has grown steadily over the years. Chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of physicians.
F8. In our view, the constellation of the evidence of:
(a) The effectiveness and cost-cost-effectiveness of chiropractic management of low-back pain.
(b) The untested, questionable or harmful nature of many current medical therapies.
(c) The economic efficiency of chiropractic care for low-back pain compared with medical care.
(d) The safety of chiropractic care.
(e) The higher satisfaction levels expressed by patients of chiropractors,
together offers an overwhelming case in favour of much greater use of chiropractic services in the management of low-back pain.

Our recommendations for reform include the following:

R1. There should be a shift in policy to encourage and prefer chiropractic services for most patients with LBP.
R2. Chiropractic services should be fully insured under the Ontario Health Insurance Plan. This one step will bring a shift from medical to chiropractic management that can be expected to lead to very significant savings in health care expenditure and even larger savings if a more comprehensive view of the economic costs of low-back pain is taken.
R3. Chiropractic services should be fully integrated into the health care system.
R4. Chiropractors should be employed by tertiary hospitals in Ontario. Hospitals already employ chiropractic in the United States with good effect. Similar recommendations have been made recently by government inquiries in Australia and Sweden, and following government funded research in the U.K. and other countries. Unnecessary or failed surgery is not only costly but also represents low quality care.
R5. Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients’ needs.
R6. Chiropractors should have access to all pertinent patient records and tests from hospitals, physicians and other health care professionals upon the consent of their patients. Access should be given upon the request of chiropractors or their patients.
R7. Since low-back pain is of such significant concern to worker’s compensation, chiropractors should be engaged at a senior level by Workers’ Compensation Board to assess policy, procedures and treatment of workers with back injuries. This should be on an interdisciplinary basis with other professional, technical and managerial staff so that there is early development of more constructive relationships between chiropractors, physicians, physiotherapists and Board staff and consultants. A very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the workers’ compensation system in Ontario.

“The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back-Pain” by Pran Manga, Ph.D., Douglas E. Angus, M.A., Costa Papadopoulos, M.H.A., William R. Swann, B.Comm. Funded by the Ontario Ministry of Health. August 1993.

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