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Low Back Chiropractic AdjustmentMost low back pain in older adults can be managed non-surgically.  Randomized controlled clinical trials have shown that chiropractic manipulative treatment (CMT) is an effective, conservative treatment option for LBP. With this in mind, the authors of a new analysis wanted to explore whether older Medicare fee-for service beneficiaries with an episode of LBP and multiple comorbidities who obtained CMT during their episode had lower costs than those who did not.

This study was an observational, retrospective study that used Medicare fee-for-service data from 2006 to 2012 to identify older (aged 66 to 99) patients who had a discrete episode of cLBP.  The study included 4 groups of patients who used: 1) only CMT; 2) conventional medical care followed by CMT; 3) CMT followed by conventional medical care; and 4) only conventional medical care.

For these 4 treatment groups, the authors used un-weighted and propensity-score weighted inflation- and price-adjusted Medicare Part A, B, and D reimbursements during the episode.  Propensity scoring is a powerful tool to strengthen causal inferences drawn from observational studies. Propensity scoring helps in selecting similar patient groups for comparison. Medicare Part A covers hospital, skilled nursing facility, home health and hospice care expenditures. Medicare Part B covers doctors’ services and other outpatient expenditures; and Medicare Part D covers prescription medications. Particular attention was given to Part B reimbursements for chiropractic care, psychiatric care, physical therapy care, and spinal manipulation therapy (SMT) provided by doctors of osteopathy (DOs) as well as to Part D reimbursements for pain medications.

The study also looked at rate of spine surgery within 1 year of the end of the episode as well as compound rates of growth for price and inflation-adjusted Medicare expenditures. In addition, the study examined expenditures for psychiatric visits and pain medications.

Results:

  • Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone
  • CMT only patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode
  • Costs were greatest for patients receiving medical care alone
  • Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories
  • Patients who used only CMT had the lowest Part A and Part B expenditures per episode day, although there was no indication of lower psychiatric or pain medication expenditures associated with CMT

Key Points:

  • Among older, multiply-comorbid Medicare beneficiaries with a chronic low back pain episode, chiropractic manipulative treatment was associated with lower overall episode costs and lower episode costs per day
  • Use of CMT was associated with lower total Part A and Part D Medicare cost growth for multiply-comorbid patients with chronic low back pain episodes over the course of the study period
  • The authors found overall Medicare cost-savings associated with use of chiropractic care
  • There was no evidence of lower psychiatric or pain medication expenditures associated with CMT

Reference:

Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities. J Manipulative Physiol Ther. 2016 Feb 19. pii: S0161-4754(16)00007-5.

Podcast

Drs. Cindy Peterson and Kim Humphreys

Drs. Cindy Peterson and Kim Humphreys join me to talk about cervical and lumbar disc herniation comparative effectiveness studies involving spinal manipulation compared to nerve root injections. We also discuss spinal manipulation for neck pain with and without dizziness as well as for chronic low back pain.

Cynthia Peterson, RN, DC, DACBR, M.Med.Ed. has worked as a chiropractic radiologist, researcher and educator in 4 countries.  She retired from her positions as Professor and researcher, Radiology Department, Orthopaedic University hospital Balgrist and Professor, Chiropractic Medicine Programme, University of Zürich in 2017. Dr. Peterson has published numerous research studies in many journals including ‘Spine’, European Spine Journal, ‘American Journal of Roentgenology’, ‘JMPT’ and ‘Skeletal Radiology’.  She is currently a Visiting Professor for the Chiropractic Department in the Faculty of Health at the University of Johannesburg, South Africa and is the Quality Assurance Consultant for the European Council on Chiropractic Education.

Barry Kim Humphreys, BSc, DC, PhD, is Professor Emeritus, Faculty of Medicine, University of Zurich. He retired in July 2017, after 9 years as the first Professor for Chiropractic Medicine in Switzerland. During this time, Professor Humphreys was responsible for the development and accreditations of the chiropractic education program, research portfolio and teaching clinic within the university, medical faculty and teaching hospital. Professor Humphreys is a graduate of the University of British Columbia (BSc), Canadian Memorial Chiropractic College (DC), and the University of Southampton, UK (PhD). He has been Academic Dean, Anglo-European College of Chiropractic, Dean of Graduate Education and Research, CMCC and Professor, Chiropractic Medicine, University of Zurich. He has been active in research including chiropractic clinical outcome studies for back and neck pain, functional MRI studies of chronic pain patients and back pain in various gravitational environments (parabolic flight).

Please view Drs. Cindy Peterson and Kim Humphreys research at researchgate.net (Peterson) as well as at researchgate.net (Humphreys).

View all of the podcast episodes at chiropracticscience.com

Here are the articles we discuss in this episode:

1. Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy.
  Peterson CK, Pfirrmann CW, Hodler J, Leemann S, Schmid C, Anklin B, Humphreys BK.
  J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):210-7. doi: 10.1016/j.jmpt.2016.02.004. Epub 2016 Mar 31.
  PMID: 27040033 [PubMed – indexed for MEDLINE]
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2. Symptomatic magnetic resonance imaging-confirmed lumbar disk herniation patients: a comparative effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either high-velocity, low-amplitude spinal manipulative therapy or imaging-guided lumbar nerve root injections.
  Peterson CK, Leemann S, Lechmann M, Pfirrmann CW, Hodler J, Humphreys BK.
  J Manipulative Physiol Ther. 2013 May;36(4):218-25. doi: 10.1016/j.jmpt.2013.04.005. Epub 2013 May 22.
  PMID: 23706678 [PubMed – indexed for MEDLINE]
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3. Comparison of outcomes in neck pain patients with and without dizziness undergoing chiropractic treatment: a prospective cohort study with 6 month follow-up.
  Humphreys BK, Peterson C.
  Chiropr Man Therap. 2013 Jan 7;21(1):3. doi: 10.1186/2045-709X-21-3.
  PMID: 23295018 [PubMed] Free PMC Article
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4. An observational study on trajectories and outcomes of chronic low back pain patients referred from a spine surgery division for chiropractic treatment.
  Wirth B, Riner F, Peterson C, Humphreys BK, Farshad M, Becker S, Schweinhardt P.
  Chiropr Man Therap. 2019 Feb 5;27:6. doi: 10.1186/s12998-018-0225-8. eCollection 2019.
  PMID: 30766664 [PubMed – indexed for MEDLINE] Free PMC Article
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Dr. Rubinstein and I discuss his latest paper that will appear soon in the British Medical Journal regarding his systematic review of spinal manipulative therapy and chronic low back pain. Sidney Rubinstein is an associate professor at the VU University, Amsterdam and adjunct research professor at Southern California University of Health Sciences (SCUHS). He is also a registered epidemiologist in the Netherlands. He has more than 60 publications in international peer-reviewed journals, including three systematic reviews in the Cochrane Library.

His research focuses on effectiveness and cost-effectiveness of interventions in musculoskeletal disorders. His broader goals are to lessen the burden of neck and low-back pain to society by providing high-quality scientific evidence. The projects that he currently supervises are strongly embedded in clinical practice, including the PTED trial, Warrior Trial, an IPD (individual patient data) meta-analysis on spinal manipulative therapy for chronic low-back pain and a large, international observational study in chiropractic care in the elderly (BACE-C cohort study).

One of his passions lies in systematic reviews and meta-analysis as these types of overviews represent a crucial link in the practice of evidence-based health care. He is actively involved in conducting and supervising these reviews, including a position on the Associate Editorial Board of the Cochrane Back and Neck Review Group.  His reviews are quite diverse. One of the more recent Cochrane reviews focused on complications of trocar types for laparoscopic surgery, while another has examined the effectiveness of exercise for acute low back pain. An update of the Cochrane review on the effect of spinal manipulative therapy for chronic low-back has been accepted by the BMJ and should be published soon.

Dr. Rubinstein currently supervises 5 PhD students as well as MSc students, and teaches methodology of systematic reviews and meta-analyses at various levels, including BSc, MSc and PhD students. One chiropractor has received his PhD under Sidney’s supervision, while others are completing theirs.

Here is a link to Dr. Rubinstein’s research at researchgate.net.

Here is a link to Dr. Rubinstein’s page at Vrije Universiteit Amsterdam

The article we discuss in this episode is available now at https://www.bmj.com/content/364/bmj.l689

Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l689 (Published 13 March 2019) Cite this as: BMJ 2019;364:l689