Evidence Based Chiropractic Rehabilitation
Randall C. McLeod DC FCCRS(c)
Because for neuromusculoskeletal problems, it is the most effective and cost effective care currently available.
Effective – There is a very impressive body of good evidence supporting the utilization of chiropractic services for the treatment of numerous conditions which are either inherently musculoskeletal in nature or that have a musculoskeletal component or co-morbidity. Independent studies conducted by the governments of Quebec (1), Ontario (2) and New Zealand (3) as well as the Rand Corporation (4) have unequivocally stated that for the treatment of neck and back pain (the single most common ailment for which patients report for care) (5), chiropractic is the most effective treatment currently available (7,8,9). Even more impressive is that these results hold up for both short term and long term outcomes (6).
Cost Effective – RCTs (Randomly Controlled Trials), Retrospective and WCB studies also show cost effectiveness to be as much as 10-fold superior for chiropractic care (7,8,9). A 4-year retrospective data analysis published in the Archives of Internal Medicine showed that simple insurance parody of access to chiropractic not only lowered the overall cost of care, it also freed up critical hospital and diagnostic resources (10).
Best Qualified – The New Zealand Royal Inquiry specifically notes that chiropractors are by far the mot qualified professionals to perform Spinal Manipulative Therapy (SMT)(3). The Guidelines for the Management of Chronic Pain (Ontario 2000) support the application of SMT and multi-modal rehabilitation for the management of chronic musculoskeletal pain (pp. 13). An RCT which was published in “Spine” revealed an improved efficacy of 27.3% versus 5% (greater than 5-fold superiority) for SMT versus pharmacological management of chronic spinal pain (15).
It gets more people back to work and back to life.
Recurrent back pain occurs at rates ranging from 45% to 62% (12) and chronic back pain (from 5 to 15% of acute injuries) (12) is responsible for up to 90% of the costs related to back conditions, with 60% of that cost directly related to indemnity (12). Some newer studies are showing that after a period of 7 to 10 years, the rate of chronic pain appears to be approaching 30%.
In dealing with these very challenging problems, it is found that the current practices of seeking out histopathology through various types of imaging studies seem to add little valuable information on which to base our treatment (12) On the positive side, treating functional pathology with a biopsychosocial approach (Waddell – 12) (as advocated by the rehabilitation sciences) has been demonstrated to improve efficacy rated by factors of 2 to 4-fold (12).
Evidence Based Care?!
Setting and measuring the achievement of functional goals.
In the British Journal of Surgery, a recent article noted that “evidence based medicine requires evidence.” (13) That is to say, that as health professionals, we have a tendency to rely on our clinical judgment rather than looking to the literature for the care models which have the best support and then follow that care with appropriate outcome measures in order to determine if our management is having the desire effect.
Our facility utilizes numerous standardized outcome instruments for tracking subjective (pain scales, disability indexes,) objective (inclinometry, dynamometry, physical abilities evaluations, sEMG and thermography) and psychosocial (Fear Avoidance Questionnaire and SF 12 or 36) factors in order to monitor a patient’s progress. Some of these obviously have stronger evidence than others, but all are supported in the literature. We customarily repeat these measures at recommended intervals of 9 to 12 visits to insure continued progress and optimal results . These results are forwarded to the referring practitioner in order to maintain good communication and, ultimately, the best possible outcomes.
More Than Just Backs.
The treatment protocols used in rehabilitation have also been demonstrated to be highly effective for the care of extremities, myofascial syndromes, neck, headaches, migraines and TMJ.
What About Safety?
“. . . we find that chiropractic treatment in safe.” New Zealand Report (1979) pp. 130-131
More recently, from the Annals of Internal Medicine, a review of 160 reports and studies of chiropractic published in 2002 stated that “The apparent rarity of these accidental events (stroke) has made it difficult to assess the . . . risk. No serious complication has been noted in more than 73 controlled, clinical trials or in any prospectively evaluated care series to date.” (14) (emphasis ours.) And for lower backs, even in cases with sciatica and definitive evidence of nerve root entrapment, up to 86% have been treated successfully (12); as well, lumbar herniated nucleus pulposus can be treated non-operatively with a high degree of success (12).
1. Spitzer W.O., et al (1995) Whiplash Associated Disorders (WAD): Redefining Whiplash and its Management: Quebec Task Force on Whiplash Associated Disorders
2. Manga P., Angus D., Papadopolous C., Swan W., (1993) The Effectiveness and Cost Effectiveness of Chiropractic Management of Low Back Pain, Kenilworth Publishing, Ottawa
3. Chiropractic In New Zealand (377 pages), (1979), PD Hasselberg, Government Printer, Wellington NZ
4. Shekelle P.G., Adams A.H., Chassin M.R., Hurwitz E.I. Phillips R.B., Brook R.H. (1991) “The Appropriateness of Spinal Manipulation for Low Back Pain. Project Overview and Literature Review, RAND, Santa Monica, California
5. Link BK, Lafferty WE, et al, (2005), “The Role of Alternative Medical Providers for the Outpatient Treatment of Insured Patients with Back Pain”, Spine 30 (12): 1454-1459
6. Meade T.W., Dyer S., Browne W., Townsend J., Fran A.O., (1990) A Randomized Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain, British Medical Journal Vol. 300 pp. 1431-37
7. Meade T.W. et al (1995) Follow up study to #6 above BMJ Vol. 311 pp. 349-51
8. Jarvis K.B., Phillips R.B., Morris E.K. (1991) Retrospective “Cost Per Case analysis of Back Injury Claims of Chiropractic versus Medical Management for Conditions with Identical Diagnostic Codes”, Journal of Occupational Medicine, Vol. 33(8) pp. 847-852
9. Ebrall P.S. (1992) “Mechanical Low back Pain: A Comparison of Medical and Chiropractic Management Within the Australian WorkCare Scheme” Chiropractic Journal of Australia, Vol. 22 (2) pp. 47-53
10. Legorreta A.P. et al, (2004) “Comparative Analysis of Individuals With and Without Chiropractic Coverage” Archives of Internal Medicine 2004; 164:1985-1992
11. Giles, Lynton G.F. DC, PhD *+ Mueller, Reinhold PhD, (2003) Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation, Spine 28(14):1490-1502, July 15, 2003
12. Liebenson, (1996) “Rehabilitation of The Spine A Practitioners Manual” Ch 1 pp. 3-11
13. Rothenberger D.A., (2004) “Evidence Based Practice Requires Evidence”, British Journal of Surgery, Vol. 91, Issue 11, Nov. 2004
14. Meeker W.C., Haldeman S., (2002) “Chiropractic: A profession at the Crossroads of Mainstream and Alternative Medicine”. Annals of Internal Medicine, Feb. 5, 2002, Vol. 136, No 3