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Musculoskeletal Chest Pain and the Cost-Effectiveness of Chiropractic Care

chestpain1Chest pain is a common presentation to health care practitioners, and requires careful and often urgent assessment. Although it is critical to rule out potentially life-threatening conditions, in the general practice/primary care setting, musculoskeletal conditions are the most common causes of chest pain (1). The evidence suggests a prevalence in the general practice population of from 20.6%to 46.6%. By contrast, musculoskeletal conditions were diagnosed in only 6.2% of patients presenting to the emergency department (1).  An attack of acute chest pain can have many causes, not all of which are critical.  Once serious pathology such as myocardial infarction (heart attack) has been ruled out, these patients are often discharged from the emergency department (ED) with the diagnosis of undifferentiated chest pain, i.e. chest pain of unknown origin (2). An often over-looked cause of acute undifferentiated chest pain is pain from the neck and mid back (thoracic spine), creating a sub-category of this condition often called ‘musculoskeletal chest pain’.

A recent Danish randomized controlled trial by Dr. Stochkendahl, a chiropractor and PhD clinical researcher compared chiropractic care, including spinal manipulation of the thoracic and/or cervical spine to the normal self-management program for patients presenting to a University Hospital with acute musculoskeletal chest pain (3, 4) The study results demonstrated improvement in self-perceived chest pain and less pain intensity in favor of chiropractic care. In addition, patients receiving chiropractic care reported significantly less thoracic spine and shoulder-arm pain. This study suggested that chiropractic care could help speed recovery for patients with acute musculoskeletal chest pain presenting to the emergency department.

A study that just came out in 2016 has examined the cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain (5). An interesting finding is that patients with non-specific chest pain feel equally or more disabled than patients with cardiac chest pain and are a major burden on healthcare resources. This new study found that in terms of health-related quality of life, primary care in the form of chiropractic care has similar effectiveness as self-management in patients with musculoskeletal chest pain. For patients with musculoskeletal chest pain, community-based chiropractic care is more cost-effective than self-management as it is associated with fewer hospital admissions and lower healthcare costs (5).

 

References:

1: Winzenberg T, Jones G, Callisaya M. Musculoskeletal chest wall pain. Aust Fam Physician. 2015 Aug;44(8):540-4. PubMed PMID: 26510139.

2: Donovan J, Cassidy JD, Cancelliere C, Poulsen E, Stochkendahl MJ, Kilsgaard J, Blanchette MA, Hartvigsen J. Beyond the spine: a new clinical research priority.  J Can Chiropr Assoc. 2015 Mar;59(1):6-12. PubMed PMID: 25729080; PubMed Central PMCID: PMC4319449.

3: Stochkendahl MJ, Christensen HW, Vach W, Høilund-Carlsen PF, Haghfelt T, Hartvigsen J. Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome. J Manipulative Physiol Ther. 2012 Jan;35(1):7-17. doi: 10.1016/j.jmpt.2010.11.004. Epub 2011 Dec 19. PubMed PMID: 22185955.

4: Christensen HW, Vach W, Gichangi A, Manniche C, Haghfelt T, Høilund-Carlsen PF. Manual therapy for patients with stable angina pectoris: a nonrandomized open prospective trial. J Manipulative Physiol Ther. 2005 Nov-Dec;28(9):654-61. PubMed PMID: 16326234.

5: Stochkendahl MJ, Sørensen J, Vach W, Christensen HW, Høilund-Carlsen PF, Hartvigsen J. Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain. Open Heart. 2016 May 4;3(1):e000334. doi: 10.1136/openhrt-2015-000334. eCollection 2016. PubMed PMID: 27175285.

 

 

 

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Lower Medicare Costs for Chiropractic Users with Chronic Low Back Pain and Multiple Comorbidities

BackacheManaging and controlling health care expenditures is a top priority.  Multiple comorbidities in the aging population has become more prevalent likely because of the extended lifespan experienced in the U.S. over the last few decades.  It is estimated that more than sixty percent of Americans over age 65 have multiple chronic conditions, and twenty-three percent of Medicare beneficiaries have 5 or more chronic conditions.

Patients with chronic low back pain (cLBP) have been thought to present to our offices with high prevalence of psychological, somatoform, and musculoskeletal comorbidity. The persistence of LBP may contribute to the development of these disorders and comorbidities have also been associated with poor outcome of LBP. Additionally, patients with comorbidities present with worse physical and psychosocial functioning, poorer response to treatment, and higher rates of health care utilization than other patients suffering from LBP.

The care of individuals with chronic conditions is estimated to account for 78% of US healthcare spending, and Medicare beneficiaries with more than 1 chronic condition account for 95% of all Medicare spending.  Not surprisingly, those with more than 5 chronic conditions account for 66% of Medicare spending. The probability that patients will use expensive health care such as hospital care increases substantially when there are comorbidities.

The rising prevalence of low back pain (LBP) among Medicare beneficiaries, the growing costs of its treatment, and the high use and costs of prescription drugs suggest an essential need to identify suitable, cost-effective, non-drug, non-surgical treatments for older patients with LBP.

Most LBP 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 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.

Methods:

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 episode was defined as lasting at least 90 days and was preceded and followed by 180 days in which no LBP diagnosis was noted.  Additionally, each patient also had an additional musculoskeletal disorder diagnosis and a mental health disorder. If a patient had multiple episodes during the study period, only the first episode was included in the analysis.

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

Source: 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. doi: 10.1016/j.jmpt.2016.01.006.

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Chiropractic Reduces Cost and Medication Use

back pain chiropractic

Up to 84% of the general population has been found to report low back pain (LBP) symptoms at some point during their lifetime.  Another staggering fact is that low back pain is the leading cause of disability worldwide affecting nearly one in ten people. Not surprisingly then, back pain is the second most common symptom-related reason for clinician visits in the United States.

The costs for spinal conditions continue to rise. Consider that back pain has substantial recurrence rates that may affect 40% to 50% of patients within 6 months and 70% within 12 months.  Current evidence suggests that the natural history of LBP is alike chronic conditions such as asthma, marked by chronic mild symptoms and periodic exacerbations. These developments have highlighted that LBP is a priority for employers focusing on workforce health and productivity (H&P).  Employers are seeking to maximize the ratio of outcomes achieved relative to costs incurred (ie, value) for the investments that they are making in their employees.  Furthermore, employers are in the unique position of being able to determine what treatments actually cost and how effective they are in their workforce.

The authors of this article point out that previous research has found that patients receiving chiropractic care have lower associations of probability of disability recurrence than patients of physicians and physical therapists.  They also state that early use of magnetic resonance imaging (MRI) has been linked to prolonged disability, higher costs, and greater use of surgery without evidence of benefit on health and function.

The goals of this study were to assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain.

—The study involved a retrospective time series analysis of tracked episodes of three types of ICD-9 code–identified back problems (n = 14,787) during 2001 to 2009 from a Fortune 500 company.

—The sample consisted of back pain episodes stratified into 3 groups:
#1: LBP (low back pain) with neurologic findings  (LBP/neuro) (n=1837)
#2: LBP with no neurologic findings (LBP/nonneuro) (n=8569)
#3: Other back (n=4381)

Of all employees, 39.4% of employees had at least one back pain episode and many had multiple episodes of LBP.  Total costs (direct/indirect) per employee were calculated per year.

Results indicated that 5 overall episode treatment patterns emerged (overall sample percentage in parentheses):

  1. Information and Advice (TalkInfo): simple office visits, lab tests, emergency department or hospital visits, talk therapy, or visits involving imaging (59%).
  2. Complex Medical Management (Complex MM): visits for nerve blocks, surgeries, or comparable procedures. Any ties with other categories went to this category (2%).
  3. Chiropractic (Chiro): number of visits to a chiropractor was greater than 1 and comprised the plurality or greater of procedures. This included cases involving manipulation billed as PT if the manipulation occurred on the same day (11%).
  4. Physical therapy (PT): number of visits to a PT was greater than 1 and comprised the plurality or greater of procedures. Physical therapy by itself (no chiropractor) sometimes included devices or other palliative treatments (11%).
  5. Dabble: at most one visit for physician, chiropractic, or PT care, or at most one visit to two or more of these categories (17%).

—The chiropractic group had the lowest prescription medication rates, least costs per episode of low back pain, and least guideline-incongruent use of medications and imaging.  —The chiropractic group also was the least likely to receive complex medical procedures like surgeries. —Complex medical management costs were greater than 4 times more expensive for an episode of low back pain (over 3 years) with neurological findings than chiropractic care ($6983.82 vs $28,231.5).  —Physical therapy costs were more than double per episode of low back pain (over 3 years) with neurological findings compared with chiropractic care ($6983.82 vs $17,193.92). —Similar cost savings in favor of chiropractic were found for an episode of low back pain (over 3 years) without neurological findings (chiropractic care = $6768.43, complex medical management = $29,344.25, physical therapy = $13,448.82).

Of note is that the complex medical management approach recorded the highest rates of prescription fills for opiods, other pain medications, SSRI/SNRI/tricyclics, and anxiolytics/sedatives/hypnotics.  The PT group had the highest rates for NSAIDs, muscle relaxant, and oral steroids.

Reference: Tracking low back problems in a major self-insured workforce: toward improvement in the patient’s journey. Allen H, Wright M, Craig T, Mardekian J, Cheung R, Sanchez R, et al.  J Occup Environ Med. 2014;56(6):604-20.

 

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Lower Medicare Costs for Chiropractic Users with Chronic Low Back Pain and Multiple Comorbidities

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.

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Chiropractic Has Lowest Total Costs for Low Back Problems in a Major Self-Insured Workforce

Low Back PainStatistics tell us that up to 84% of the general population will report low back pain (LBP) symptoms at some point during their lifetime.  This leads employers seeking to maximize the ratio of outcomes achieved relative to costs incurred (ie, value) for the investments that they are making in their employees. Previous research has found that patients receiving chiropractic care have been found to record lower associations of probability of disability recurrence than patients of physicians and physical therapists.  Given these findings, the authors of this newly published article sought to assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain. Results of the study were that care congruent with 10 of 11 guidelines was linked to lower total costs. Of the five patterns of care, complex medical management reported the highest guideline-incongruent use of imaging, surgeries, and medications and had the highest health care costs.  On the other hand, chiropractic reported the lowest rates of guideline-incongruent use of imaging, surgeries, and medications and had the lowest health care costs.

http://www.ncbi.nlm.nih.gov/pubmed/24854253

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Podcast

061- Questioning the Relationship Between Chiropractic and ED Visits

Dr. Brian Anderson and I discuss the article, Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US (2022). We question the relationship between chiropractic and emergency department – ED visits in this paper. Does it makes sense that those who first saw a chiropractor had the lowest out of pocket and overall costs of care, the least hospitalizations and serious illnesses out of any provider type and yet had the highest emergency department – ED visits? Furthermore, those who first saw a chiropractor ranked second lowest of all providers for early opioid prescription, long opioid prescription, MRI/CT imaging, and surgery.

If you have not listened to Dr. Anderson’s podcast episode on chiropractic, treatment escalation, and medical services, please visit here.

Visit Dr. Anderson’s researchgate.net profile and Dr. Smith’s researchgate.net profile.

Below are the articles that are mentioned in this episode of the chiropractic science podcast.

1.Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US.Harwood KJ, Pines JM, Andrilla CHA, Frogner BK.BMC Health Serv Res. 2022 May 23;22(1):694. doi: 10.1186/s12913-022-08092-1.PMID: 35606781 Free PMC article.
2.Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review.Zouch J, Comachio J, Bussières A, Ashton-James CE, Reis AHS, Chen Y, Ferreira P.Phys Ther. 2022 Nov 1:pzac150. doi: 10.1093/ptj/pzac150. Online ahead of print.PMID: 36317766
3.Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons With Low Back Pain in Arkansas.Acharya M, Chopra D, Smith AM, Fritz JM, Martin BC.J Chiropr Med. 2022 Jun;21(2):67-76. doi: 10.1016/j.jcm.2022.02.007. Epub 2022 May 21.PMID: 35774633 Free PMC article.
4.Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries.Whedon JM, Kizhakkeveettil A, Toler AW, Bezdjian S, Rossi D, Uptmor S, MacKenzie TA, Lurie JD, Hurwitz EL, Coulter I, Haldeman S.Spine (Phila Pa 1976). 2022 Feb 15;47(4):E142-E148. doi: 10.1097/BRS.0000000000004118.PMID: 34474443
5.Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database.Marrache M, Prasad N, Margalit A, Nayar SK, Best MJ, Fritz JM, Skolasky RL.BMC Health Serv Res. 2022 Jul 2;22(1):851. doi: 10.1186/s12913-022-08255-0.PMID: 35778738 Free PMC article.
6.Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims.Anderson BR, McClellan WS, Long CR.J Manipulative Physiol Ther. 2021 Jun;44(5):372-377. doi: 10.1016/j.jmpt.2021.03.001. Epub 2021 Aug 6.PMID: 34366149
7.Prescription history of emergency department patients prescribed opioids.Hoppe JA, Houghland J, Yaron M, Heard K.West J Emerg Med. 2013 May;14(3):247-52. doi: 10.5811/westjem.2012.2.6915.PMID: 23687544 Free PMC article.
8.Interpreting the National Hospital Ambulatory Medical Care Survey: United States Emergency Department Opioid Prescribing, 2006-2010.Kea B, Fu R, Lowe RA, Sun BC.Acad Emerg Med. 2016 Feb;23(2):159-65. doi: 10.1111/acem.12862. Epub 2016 Jan 23.PMID: 26802501 Free PMC article.
9.Management of patients with low back pain in the emergency department: Is it feasible to follow evidence-based recommendations?Urrutia J, Besa P, Meissner-Haecker A, Gonzalez R, Gonzalez J.Emerg Med Australas. 2020 Dec;32(6):1001-1007. doi: 10.1111/1742-6723.13544. Epub 2020 Jun 18.PMID: 32558273
10.Imaging during low back pain ED visits: a claims-based descriptive analysis.Schlemmer E, Mitchiner JC, Brown M, Wasilevich E.Am J Emerg Med. 2015 Mar;33(3):414-8. doi: 10.1016/j.ajem.2014.12.060. Epub 2014 Dec 31.PMID: 25624075
11.Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective.Friedman BW, Chilstrom M, Bijur PE, Gallagher EJ.Spine (Phila Pa 1976). 2010 Nov 15;35(24):E1406-11. doi: 10.1097/BRS.0b013e3181d952a5.PMID: 21030902 Free PMC article.
12.Review article: Best practice management of low back pain in the emergency department (part 1 of the musculoskeletal injuries rapid review series).Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T.Emerg Med Australas. 2018 Feb;30(1):18-35. doi: 10.1111/1742-6723.12907. Epub 2017 Dec 12.PMID: 29232762 Review.
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060- Dr. Brian Anderson Discusses Chiropractic, Treatment Escalation, Medical Services

Dr. Brian Anderson

Dr. Brian Anderson DC, MPH, MS, PhD is an Assistant Professor within the Palmer Center for Chiropractic Research (PCCR) at the Palmer College of Chiropractic, where his research is focused on evaluation of nonpharmacological spine care delivery in the US. His background includes 15 years of clinical experience as a licensed chiropractic physician in a variety of settings, including private practice, a hospital-based integrative medicine center, and a chiropractic academic teaching clinic. He has also been an educator for the past 15 years, teaching courses at the undergraduate, graduate, and post-graduate level. With a passion to better understand and contribute to conservative spine care research, he enrolled in a PhD program in Health Sciences in 2015 with a focus on Health Services Research. His dissertation was titled “A Secondary Analysis Of Insurance Claims Data To Determine The Association Between Provider Type And Treatment Escalation In Musculoskeletal Disorders”, which is a topic he continues to investigate currently. In this interview, we discuss his journey from chiropractor to researcher, and several of his publications.

After graduating with his PhD in 2019, he joined the faculty at the Palmer Center for Chiropractic Research, where he participated in a pilot clinical study as a treating clinician, developed relationships with several research collaborators, and made progress towards developing his own research program.

Dr. Anderson’s research has been presented at many academic conferences, for which he has received several best paper awards. He is currently a co-investigator and primary analyst on a R15 grant titled “Spinal Manipulative Therapy vs Prescription Drug Therapy for Care of Aged Medicare Beneficiaries with Neck Pain”. He was recently awarded a 2-year Loan Repayment Award through the National Center for Complementary & Integrative Health (NCCIH), and also participated in the Fall 2022 cohort of the US Bone & Joint Young Investigators Initiative.

View Dr. Anderson’s publications at researchgate.net.

Here are the articles we discuss in this episode:

1.Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims.Anderson BR, McClellan WS, Long CR.J Manipulative Physiol Ther. 2021 Jun;44(5):372-377. doi: 10.1016/j.jmpt.2021.03.001. Epub 2021 Aug 6.PMID: 34366149
2.The Effect of Reduced Access to Chiropractic Care on Medical Service Use for Spine Conditions Among Older Adults.Davis M, Yakusheva O, Liu H, Anderson B, Bynum J.J Manipulative Physiol Ther. 2021 Jun;44(5):353-362. doi: 10.1016/j.jmpt.2021.05.002. Epub 2021 Aug 8.PMID: 34376317 Free PMC article.
3.The Relationship Between Healthcare Provider Availability and Conservative Versus Non-conservative Treatment for Back Pain Among Older Americans.Anderson BR, Yakusheva O, Liu H, Bynum JPW, Davis MA.J Gen Intern Med. 2022 Mar;37(4):992-994. doi: 10.1007/s11606-021-06889-0. Epub 2021 May 24.PMID: 34031853 No abstract available.
4.Three Patterns of Spinal Manipulative Therapy for Back Pain and Their Association With Imaging Studies, Injection Procedures, and Surgery: A Cohort Study of Insurance Claims.Anderson BR, McClellan SW.J Manipulative Physiol Ther. 2021 Nov-Dec;44(9):683-689. doi: 10.1016/j.jmpt.2022.03.010. Epub 2022 Jun 24.PMID: 35753873
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