How much Chiropractic Care is Reasonable?
This is a very common question asked by my patients. In the past, I could only suggest the patient speak to the Chiropractor and discuss the costs versus the benefits. There has been some information collected and discussed by the RAND Corporation in the early 1990’s. Recommendations of Chiropractic treatments varied between 1-5 visits a week, for 2-24 weeks. By the mid 1990’s an all Chiropractic Expert panel assembled by Rand Corporation recommended 30 visits for chronic back pain over 14 weeks.
By 2003, efficacy studies on the effects of Spinal Manipulation on chronic back pain did not demonstrate an advantage over other treatment methods. There are many ways to interpret that information. The skeptic will say it demonstrates all treatments are equally not effective. When analysing the importance of that statement, we need to understand that up to 40% of patients who receive treatments for back pain go sees a Chiropractor. Naturally, in this era of evidenced based medicine, there is research being done on the efficacy, costs, and the appropriateness of duration of treatments. Recently, in the SPINE JOURNAL, the official Journal of the North American Spine Society, a paper was submitted by Haas, Et al titled “Dose-response and efficacy of spinal manipulation of care of chronic low back pain: a randomized controlled trial“. The lead author Mitchell Haas, is a Chiropractic Physician with significant research experience.
400 participants with chronic low back pain were randomized into four groups, and received 0, 6, 12 and 18 Chiropractic Manipulations. All participants had 18 visits, 3 per week for 6 weeks. For those who did not receive Chiropractic Spinal Manipulation on the visit, they were given light massage therapy, to provide attention and touch by the provider. Followup was by phone interview on a 6, 12, 18, 24, 39, and 52 weeks from the conclusion of treatments.
You can read the study for details, but the authors conclude the number of spinal manipulations has a modest positive effect compare to gentle massage therapy. Also, 12 visits has the most favorable results. The authors also stated that “Even with 12 visits, the contribution of Spinal Manipulative Therapy to outcomes beyond that of a focused light massage delivered by a chiropractor (hands-on control) was a best modest at the 12-week primary endpoint and negligible at the 24-week primary end point”.
The study suggests there is no additive benefit for more manipulations after 12 visits over 6 weeks. Certainly clinicians may have disagreements with the results of the study. However, in the Era of evidence based medicine, each treatment will undergo efficacy and value analysis. It behooves the Chiropractic Community to develop studies to explore their recommendations, and back up the recommendations with scientific, unbiased data. The payers, which include insurance, and the government no longer accept just the clinical judgement of the medical professionals. In the end, patients can always choose to purchase these services regardless of the scientific data. Third parties, however, are starting to demand evidence of value.
To my Chiropractic Colleagues, do not run from the coming changes. Rather, start doing research and prove the need for your services. Or, develop personal bonds with patients so they can advocate for your intangible value.
- Enyinnaya EI, Anderson JG, Merwin EI, Taylor AG. Chiropractic use, health care expenditures, and health outcomes for rural and nonrural individuals with arthritis. J Manipulative Physiol Ther. 2012 Sep;35(7):515-24. PubMed PMID: 22951269