New Evidence on Spinal Manipulation

In a recent randomized controlled trial following guidelines-based care by Bishop et al. (2010), significantly greater improvement for acute mechanical low back pain of 16 weeks or less was achieved with spinal manipulative therapy than usual medical care.¹⁷ Patients receiving usual medical care had both inferior functional outcomes and higher rates of prescribed opioid analgesics (80%). Furthermore, medically managed patients received a high percentage (60%) of guideline-discordant treatment, like bed rest, x-rays and back supports. Parkin-Smith et al. (2012) showed that an evidence-based package of exercise, patient education and manual/manipulative therapy is of benefit for acute mechanical low back pain of less than 4 weeks duration.¹⁸ This outcome supports Childs et al. (2004) who indicated that spinal manipulation offers good outcomes in acute low back pain cases where the pain is of less than 16 days duration (2 weeks) and where the pain does not extend below the knee.¹⁹ In a randomized controlled trial, von Heymann et al. (2013) found that for a subgroup of patients with acute nonspecific low back pain LBP (<48 hours duration), spinal manipulation was significantly better than a non-steroidal anti-inflammatory drug (Diclofenac) and clinically superior to placebo.²⁰ Goertz et al. (2013) demonstrated that spinal manipulative therapy in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with standard care alone for men and women between 18 and 35 years of age with acute low back pain. ²¹ This evidence firmly supports the early access of patients with low back pain to assessment and appropriate treatment, including spinal manipulation where indicated, for the best possible outcome.  
 
The importance of early access to appropriate care cannot be underestimated, since the aim of appropriate care is to alter the course of the disorder, particularly since low back pain is well-known to be either episodic or progress to chronicity. Hestbaek et al. indicated that low back pain has an episodic trend in up to 80% of cases, as opposed to resolving fully, and Henschke (2008) reported that up to 30% of acute back pain becomes chronic.^22-24 Around 25% of Australians who experience low back pain continue to have persistent or recurrent episodic back pain.²⁵ Indeed, in a cohort of patients with acute low back pain in Australian primary care, prognosis was not as favourable as claimed in clinical guidelines – recovery was slow for most patients and nearly 33% of patients did not recover from the presenting episode, implying chronicity and added healthcare costs.²⁴
 
Appropriately trained musculoskeletal clinicians, such as chiropractors, musculoskeletal physicians, osteopaths and musculoskeletal physiotherapists, could facilitate access to care at a community level and also identify predictors of chronicity in affected patients, which could subsequently be addressed through health/lifestyle modification and utilisation of local healthy lifestyle programs.²⁶ For example, a package of care using the latest evidence-based management including patient education, staying active, exercise, lifestyle modification, spinal manipulative therapy and if necessary, simple analgesia, is likely to yield the best-possible outcomes.¹⁸ This “package of care” approach would be particularly useful if combined with existing and currently-funded programs focusing on lifestyle change and chronic pain prevention, such as the Medicare Local Healthy Lifestyle Program & Chronic Pain Program and the Self-Educative Pain Sessions (STEPS) program with a view to preventing chronicity.^21,27,28

Cost Analysis

A major reason for escalating healthcare costs relates to inflation; annual expenditures for spinal pain management in 1995 in the United States was calculated to be US$7.3 billion, whereas in 2007 the cost for drugs had skyrocketed some 271% to $19.8 billion, accounting for a sizable 23% portion of total direct healthcare expenditures, these trends being reflected in Australia.²⁹ Major elements accounting for this increase included the wider use of expensive drugs and spinal injections.^30,31

A systematic review of the cost-effectiveness of guideline-endorsed treatments for low back pain involving 26 studies demonstrated that spinal manipulation, interdisciplinary rehabilitation, exercise, acupuncture, or cognitive-behavior therapy all were cost-effective in individuals with sub-acute or chronic low back pain, while no evidence was found in support of medications, yoga, or relaxation.³²  Furthermore, the same study indicated that care from a general practitioner did not appear to be the most cost-effective means for managing low back pain, considering that adding spinal manipulation, exercise, behavioural counselling, and education/advice was more cost-effective than usual care from a general practitioner alone.³²  An additional  systematic review published elsewhere has supported the cost-effectiveness of spinal manipulative therapy, either alone or in combination with other treatment approaches.³³

An Australian led investigation only recently reported by Lin et al. (2013), showed that spinal manipulation is cost-effective for sub-acute and chronic low back pain and at least as cost-effective as other forms of conservative treatment.³²   Fritz et al. (2013) concluded that, at the very least, manipulative therapy is not associated with increased health care costs or utilisation of specific services following a new primary care low back pain consultation.³⁴ An earlier extensive study from the United Kingdom—the BEAM Trial—was a randomized trial based upon 181 general practices and concluded that spinal manipulation is a cost-effective addition to “best care” in general practice.³⁵
 
Recent Workers Compensation data from the USA suggest that patients with occupational spinal injuries visiting a surgeon first are significantly more likely to receive spinal surgery (42.7%) than those whose first visit was with a musculoskeletal clinician (1.5%), in this instance a chiropractor.³⁶ This association holds true even when controlling for injury severity and other measures, implying a significant cost saving and emphasises the importance of fast access to appropriate assessment and care, so that best practice care may ensue at an early stage of the disorder.

Retrospective data from the Division of Workers' Compensation Claims in Florida revealed drastic savings when chiropractic was compared to non-chiropractic care for specific low back injuries during the period 1994-1999. Here total costs per claim were less than half for chiropractic care ($7,500 vs $16,500); the average time required to reach maximum medical improvement was 37% less (161 vs 219), and the average  number  of  days  required to return to work was reduced by 30% as well (77 vs 130). Incredibly and most surprising was the fact that, during this same period, utilization of chiropractors for such injuries decreased by 75% with at most only a 15% reduction of the number of cases treated by non-chiroprac­tors.³⁷

Much the same pattern was found in Texas. In this instance, the authors retrieved over 70 articles, reports, published studies, and treaties on the costs and effectiveness of chiropractic care and analyzed data on nearly 900,000 Texas Workers Compensation Claims from 1996-2001. The expenses resulting from lower back injuries amounted to $792.6M, with lower back and neck injuries accounting for 38% of the total claims costs.  Here, chiropractors treated 30% of workers with lower back injuries but accounted for just 9.1% of the total costs and 17.5% of the medical costs. The average claim cost was $15,884, found to decrease to $12,202 when a worker with a lower back injury received at least 75% of care from a chiropractor. That figure fell to $7,632 when at least 90% of that care was given by a chiropractor.³⁸

These same trends persisted in the state of North Carolina, in which a retrospective review of 96,627 claims between  1975  and  1994  archived by the North Carolina Industrial Commission  produced  the  same compelling and ultimately unsettling data. Here it was shown that the treatment costs, total costs, and total time of disability for medical providers was $3,519, $17,673, and 176 days, respectively. The corresponding figures for chiropractic care, on the other hand, were just $663, $3,318, and 33 days.  Again, the utilization rates for medical (85.4%) and chiropractic (0.8%) providers were far from equal.³⁹

Risk Analysis

Cifuentes et al. (2011)  showed that, after controlling for patient demographics and severity, clinicians offering musculoskeletal services for back pain had a significantly lower hazard ratio for disability recurrence than those treated by medical practitioners, and the patients also had lower rates of spinal surgery and opioid analgesic use.⁴⁰ Upon return to work, patients under chiropractic care displayed superior outcomes compared to those receiving medical care or physical therapy. Interestingly, patients receiving no care also did better than individuals under MD or PT care and almost as well as those receiving chiropractic management.  Reviews of the literature reveal the rarity of morbidity and no reported cases of mortality secondary to low back spinal manipulation, and through appropriate assessment by a suitably qualified musculoskeletal clinician, contraindications to manipulative therapy may be identified early, thereby reducing treatment-related risks even further. ^41,42
 
Opioid drugs and benzodiazepines are, however, associated with much higher risks and complications related to tolerance (and escalating doses), addiction, and abuse, particularly with chronic or recurrent spinal pain syndromes. Notwithstanding, some clinical guidelines recommend the judicious use of strong analgesics and benzodiazepines, such as tramadol, oxycodone and diazepam, in acute cases of back pain of less than 4 weeks duration, even though the supporting research evidence is weak.⁴³ It is recognised however, that their use for severe pain is logical, supported by Musculoskeletal Analgesic Regime to Aid Rehabilitation (MARTAR) study and regime, developed by the WA Emergency Medicine Research Online (WAEMRO) where a graded approach to prescribing opioid analgesics is recommended based on the severity of the back pain (usually severe, acute) over the short term (usually less than 2 weeks).⁴⁴
 
The problems associated with opioid prescription seem to emerge predominantly outside of the Emergency Department setting – prescriptions for oxycodone in Australia have increased by more than 150% in 5-year period up to 2008, with 551 Australians dying as a result of accidental overdose of prescribed opioids in the same year.⁴⁵ An estimated 1300 Australians ages 15-54 died from accidental overdose of prescribed opioids in 2009/10 – “most of the existing guidelines have limited impact on what is now approaching a national epidemic”.⁴⁶ Except for the short-term treatment of acute, severe cases of back pain, where opioid and benzodiazepines are a defendable option, there is little evidence to suggest that opioids change the course of the back pain despite being effective pain-killers.⁴³ Compounding the matter are patients that put their doctors under pressure to prescribe opioids, often leading to General Practitioners (GPs) overlooking clinical guideline recommendations for non-malignant pain.⁴⁷
 
Short-term or periodic use of simple analgesia for mild-moderate acute spinal pain and opioids use for acute, severe spinal pain of less than 2 weeks is clinically defendable, respectively. However, assessment and treatment by a musculoskeletal clinician, with a view to manage acute, mild-moderate spinal pain and prevent chronicity, using a package of care that includes manipulative therapy, is clearly a safer option. Therefore, early assessment and spinal manipulative therapy by a suitably qualified musculoskeletal clinician is recommended as first-line treatment for acute spinal pain, outside of cases of severe spinal pain seen in the Emergency Department.

Workforce Capacity & Community Engagement

Health care workforce analysis by the Productivity Commission highlighted the desirability of ‘task substitution’ and a recent new-graduate healthcare practitioner survey identified emerging healthcare workforce capacity that could cater for the multi-disciplinary community-based approach for non-malignant spinal pain.^48,49 In particular, appropriately trained musculoskeletal clinicians such as chiropractors, musculoskeletal physicians, osteopaths and musculoskeletal physiotherapists are able to fill the gap by providing evidence-based care based on up-to-date clinical guidelines.⁵⁰
 
The preparedness of the musculoskeletal professions for providing appropriate care is demonstrated by the development of care algorithms based on the current best-available research evidence.⁵¹ Such algorithms would help healthcare gate-keepers, such as GPs, to steer suitable patients towards early access and appropriate treatment for their back pain, with a view to reduce morbidity and prevent chronicity. An algorithm, such as the one proposed by Baker et al (2012) requires little modification to conform to Western Australian requirements and can be used in various professional contexts. The chiropractic profession, for example, has also developed a consensus-led definition and approach to wellness/wellbeing care that would act as a model to facilitate to correct management and treatment of non-malignant back pain within a multidisciplinary context. In fact, musculoskeletal clinicians, such as chiropractors, already implement the majority of the health promotion and wellness/wellbeing strategies recommended in both the SPMoC (2009) and the Western Australian Health Promotion Strategic Framework 2012–2016 with their private patients.⁵² The same would easily translate to the public healthcare system and be used by other musculoskeletal clinicians.