Chiropractic For Neck Pain?
On October 12, 2009, Mercer Health and Benefits released a study titled:
Do Chiropractic Services for the Treatment of Low Back and Neck Pain Improve the Value of Health Benefits Plans?
An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending
A Google Internet search of Mercer states:
“Mercer is a leading global provider of consulting, outsourcing and investment services. Mercer works with clients to solve their most complex benefit and human capital issues, designing and helping manage health, retirement and other benefits. It is a leader in benefit outsourcing. Mercer’s investment services include investment consulting and multi-manager investment management. Mercer’s 18,000 employees are based in more than 40 countries. The company is a wholly owned subsidiary of Marsh & McLennan Companies, Inc., which lists its stock on the New York, Chicago and London stock exchanges.”
PhysiciansNiteesh Choudhry,MD, PhD, and Arnold Milstein, MD, MPH, author this Mercer report.
Dr. Niteesh Choudhry is fromHarvardMedicalSchoolwhere he is an Assistant Professor of Medicine and an Associate Physician in the Division of Pharmaco-epidemiology and Pharmaco-economics. He is also associated with the Hospital Program at Brigham and Women’s Hospital where he practices inpatient general internal medicine and is actively involved in resident education.
Dr. Arnold Milstein is from Mercer Health and Benefits inSan Francisco,Californiawhere he is the Medical Director at Pacific Business Group on Health, the largest employer health care purchasing coalition in theUS. At Pacific Business Group he is the National Health Care Thought Leader. His work focuses on improving managed care programs for large purchasers and for the government.
Dr. Milstein’s 40 book chapters and published articles have centered on managed care program design. Dr. Milstein is Mercer’s chief physician and national thought leader, and he earned the Elliott M. Stone Award of Excellence in Health Data Leadership from the National Association of Health Data Organizations (NAHDO) at its annual meeting inAlexandria,VA, on October 15, 2009. The NAHDO stated:
“Through this award, NAHDO honors Dr. Milstein’s strong advocacy of public comparative health care provider performance and public reporting. Dr. Milstein has successfully advocated for quality and pay-for-performance initiatives at the Centers for Medicare and Medicaid Services. As a national thought leader, his support of the state health care data reporting programs and their missions to provide health care data for policy and market purposes has been, and will continue to be, essential to the success and advancement of these databases.”
The National Association of Health Data Organizations (NAHDO) is a national, not-for-profit membership organization dedicated to improving health care through the collection, analysis, dissemination, public availability, and use of health data. NAHDO provides leadership in health care information management and analysis, promotes the availability of and access to health data, and encourages the use of these data to make informed decisions and guide the development of health policy. NAHDO provides information on current issues and strategies to develop a nationwide, comprehensive, integrated health information system, sponsors educational programs, provides assistance, and serves as a forum to foster collaboration and the exchange of ideas and experiences among collectors and users of health data.
Business Insurance magazine selected Dr. Milstein as “one of the 20 people who has made a difference in employee benefits management in the past 20 years.” Last year’s New England Journal of Medicine’s series on employer sponsored health insurance described him as a “pioneer” in employer efforts to advance quality.
In October 2006 Dr. Milstein was elected to theInstituteofMedicine. He is a member of the Medicare Payment Advisory Commission. Since January 2002, Dr. Milstein has also served on the Strategic Advisory Council of the National Quality Forum.
Dr. Milstein’s work focuses on health care purchasing strategy, the psychology of clinical performance improvement and clinical innovations that reduce total health care spending. Among his many accomplishments in the quality field have been co-founding both the Leapfrog Group and the Consumer-Purchaser Disclosure Project. He heads performance measurement activities for both initiatives and is a Congressional MedPAC Commissioner.
Dr. Milstein holds a medical degree fromTuftsUniversityand a master’s degree in health services planning from theUniversityofCalifornia,Berkeley. He received a bachelor’s degree in economics fromHarvardUniversity. He is an Associate Clinical Professor at theUniversityofCalifornia,San FranciscoMedicalCenterand a Worldwide Partner at Mercer.
Tom Elliott, president of Mercer’s global health and benefits business and a member of the firm’s global executive committee made these comments pertaining to Dr. Milstein:
“As the leader in providing innovative health care solutions to employers, Mercer takes great pride in celebrating the accomplishments of Arnie Milstein, who has had such a profound impact on how health care is delivered in the US. At a time when there is greater pressure than ever to deliver quality health care and at the same time control costs, we need innovative leaders who challenge employers, providers, health plans and policy makers to change their business models. Accurate and transparent data is essential in order to improve the delivery and efficacy of health care. Dr. Milstein has been a driving force behind improving the efficiency of the delivery system and his work has certainly influenced the national initiative to bridge the quality gap.”
The New England Journal of Medicine’s series on employer-sponsored health insurance described Dr. Milstein as a “pioneer” in national efforts to advance quality of care. He was selected for the highest annual award of the National Business Group on Health for distinguished innovation in health care cost reduction and quality gains. He was elected to theInstituteofMedicineof the National Academy of Sciences and is a faculty member atUniversityofCalifornia,San Francisco, Institute for Health Policy Studies.
This biographical information on Dr. Niteesh Choudhry and Dr. Arnold Milstein shows that there are none more qualified to present an evidence-based assessment on the value to Health Benefits Plans of chiropractic services.
This report (Mercer) by Drs. Choudhry and Milstein is twelve pages in length and cites 18 references from the National Library of Medicine PubMed database. A complete copy of the report can be accessed at www.f4cp.org.
The Executive Summary of the report makes the following points:
1) “Low back and neck pain are extremely common conditions that consume large amounts of health care resources.”
2) “Chiropractic care, including spinal manipulation and mobilization, are used by almost half of theUSpatients with persistent back-pain seeking out this modality of treatment.”
[This is an important point. It indicates that patients seek chiropractic treatment primarily for the management of chronic spinal musculoskeletal conditions. It is established that these chronic problems are both expensive and problematic because they do not spontaneously resolve and those suffering from these chronic complaints tend to seek the help from multiple healthcare providers].
3) “The peer-reviewed scientific literature evaluating the effectiveness ofUSchiropractic treatment for patients with back and neck pain suggest that these treatments are at least as effective as other widely used treatments.”
4) “Chiropractic care is more effective than other modalities for treating low back and neck pain.”
5) Pertaining to the total cost of care per year:
“For neck pain, chiropractic physician care reduces total
annual per patient spending by $302 compared to medical
Importantly, these authors indicate that chiropractic care
is known to reduce the need for drug treatment.
Additionally, the cost of medical physician care noted above
did not include the cost of drug spending. Consequently, the
“Because we were unable to incorporate savings in drug spending commonly associated with US chiropractic care, our estimate of its comparative cost effectiveness is likely to be understated.”
“When considering effectiveness and costs together, chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost- effectiveness thresholds.”
6) “Our findings in combination with existingUSstudies published in peer-reviewed scientific journals suggests that chiropractic care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered inUShealth benefit plans.”
7) “The addition of chiropractic coverage for the treatment of low back and neck pain at prices typically payable in US employer-sponsored health benefit plans will likely increase value-for-dollar by improving clinical outcomes and either reducing total spending (neck pain) or increasing total spending (low back pain) by a smaller percentage than clinical outcomes improve.”
In their paper, Drs. Choudhry and Milstein note that neck pain is extremely common in theUnited States, and it consumes large amounts of health care resources. They note:
- About 14% of theUSadult population report neck pain in a year.
- TheUnited Statesannual spending for spine-related problems is about $85 billion.
Drs. Choudhry and Milstein note that vast scientific
literature has evaluated the cost effectiveness of chiropractic treatment for patients with common types of back and neck pain, which support these conclusions:
“Chiropractic care is at least as effective as other widely used therapies for low back pain.”
“Chiropractic care when combined with other modalities, such as exercise, appears to be more effective than other treatments for patients with neck pain.”
In this study, Drs. Choudhry and Milstein assessed whether chiropractic care was cost-effective by applying the widely-accepted standard “quality-adjusted life years,” or QALYs to existing studies that compared chiropractic services to medical physical services and physical therapy services. “Quality-adjusted life years,” or QALYs are “a standard means assessing both the length and quality of a patient’s life.” Studies show that treatments with cost-effectiveness ratios below $50,000 to $100,000 per QALY are considered to be cost effective.
RESULTS FOR NECK PAIN:
- Patients who received chiropractic care for neck pain “achieved better clinical outcomes at lower costs than medical physician care.”
- The cost of medical physician care for neck pain was $579 per patient. The cost of chiropractic care for neck pain was $277 per patient, $302 less than medical care.
- Compared to medical physician care for neck pain, chiropractic care would save $6,035 per QALY (-$6,035). If chiropractic care cost $100 per visit, the savings per QALY would still be $5,875 per patient.
- Exercise-only care for neck pain costs $952 per case, which is $373 more than medical-only care and $677 more than chiropractic-only care. Yet, exercise only care was less effective than chiropractic, costing $18,665 per QALY, or about 4 times more than chiropractic-only care (at -$6035).
- “If exercise therapy were provided by chiropractors instead of physical therapists, one-year costs would fall to $464, resulting in savings of $114 per [insurance] beneficiary.” As attractive as this is, the combination of exercise plus chiropractic manipulation was less effective and more costly than chiropractic-only care.
Drs. Choudhry and Milstein make the following concluding remarks:
“Using data from high-quality randomized controlled European trials and contemporary Unites States based average unit prices payable by commercial insures, we project that insurance coverage for chiropractic coverage for chiropractic physician care for low back and neck pain for conditions other than fracture and malignancy is likely to drive improved cost-effectiveness of United States care.”
“For neck pain it is also likely to reduce total United States health care spending.”
“These favorable results would likely occur within a 12-month timeframe.”
“In combination with the existing United States-based literature, our findings support the value of health insurance coverage of chiropractic care for low back and neck pain at average fees currently payable by Unites States commercial insurers.”
The article by Mercer Health and Benefits is a unique analysis of the costs and effectiveness of chiropractic in the management of low back and neck pain as compared to medical care and physiotherapy-led exercise. The standard used by the authors was the cost per quality-adjusted life year, or QALY. The analysis showed chiropractic care to be extremely effective for the cost of the service. In the case of low back pain, the cost of chiropractic per quality-adjusted life year was $1,837, which the authors labeled as “extremely favorable.” In the case of neck pain, chiropractic care was the most cost effective service, and its improvement in the quality-adjusted life year showed that if chiropractic care is used in the management of neck pain there would be a savings of $6,035 per person per year.
When insurance companies evaluate the cost effectiveness of various benefits they cover, it seems prudent that they include chiropractic in the management of both low back and neck pain.
Two additional studies have added to the support for spinal manipulation in the management of neck pain this year (2012). Both of these studies are reviewed here:
Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain
A Randomized Trial
Annals of Internal Medicine
January 3, 2012; Vol. 156; pp. 1-10
Gert Bronfort, DC, PhD; Roni Evans, DC, MS; Alfred V. Anderson, DC, MD; Kenneth H. Svendsen, MS; Yiscah Bracha, MS; and Richard H. Grimm, MD, MPH, PhD
Dr. Gert Bronfort, the lead author of this study, had 54 articles in the PubMed database search of the National Library of Medicine. Dr. Bronfort was awarded the Researcher of the Year by the Foundation For Chiropractic Education in 2009. Dr. Bronfort is fromNorthwesternHealthScienceUniversity inMinneapolis,MN.
This study was funded by theNationalCenterfor Complementary and Alternative Medicine of the National Institutes of Health of theUnited States. The authors note that mechanical neck pain is a common condition that affects an estimated 70% of persons at some point in their lives. This study sought to determine the relative efficacy of chiropractic spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term. This is a randomized, controlled trial using 272 subjects aged 18 to 65 years who had nonspecific neck pain for 2 to 12 weeks. The intervention was 12 weeks of SMT, medication, or HEA.
The primary measurement outcome was participant-rated pain, measured at 2, 4, 8, 12, 26, and 52 weeks after randomization. Secondary measures were self-reported disability, global improvement, medication use, satisfaction, general health status (Short Form-36 Health Survey physical and mental health scales), and adverse events. Neck motion was performed at 4 and 12 weeks.
Results: For neck pain, chiropractic spinal manipulation had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks, and HEA was superior to medication at 26 weeks.
The authors concluded that for participants with acute and subacute neck pain, chiropractic spinal manipulation was more effective than medication in both the short and long term.
The chiropractic spinal manipulation focused on manipulation of areas of the spine with segmental hypomobility. The specific number of manipulations over the 12 weeks was left to the discretion of the chiropractor, based on manual palpation of the spine and associated musculature and the participant’s response to treatment.
The home exercise was advice that was provided in two 1-hour sessions. The therapists provided instruction, primarily focusing on simple self-mobilization exercise (gentle controlled movement) of the neck and shoulder joints, including neck retraction, extension, flexion, rotation, lateral bending motions, and scapular retraction, with no resistance. Participants were instructed to do 5 to 10 repetitions of each exercise up to 6 to 8 times per day. A booklet (McKenzie R. Treat Your Own Neck. 3rd ed.Waikanae,New Zealand: Spinal Publications; 2002) of prescribed exercises was provided.
The medication group was provided by a licensed medical physician, with the focus of treatment on prescription medication. The first line of therapy was nonsteroidal anti-inflammatory drugs, acetaminophen, or both.
Participants who did not respond to or could not tolerate first-line therapy received narcotic medications. Muscle relaxants were also used.
The authors made these comments:
“Spinal manipulation therapy was superior to medication at the end of treatment and during follow-up in terms of global improvement, participant satisfaction, and SF-36 –assessed physical function; SMT was also superior to medication in measures of long-term medication use.”
“The SMT and HEA groups performed similarly on most of the secondary outcomes, although SMT performed better than HEA for satisfaction with care in both the short and long term.”
“Spinal manipulation therapy and HEA led to similar short- and long-term outcomes, but participants who received medication seemed to fare worse, with a consistently higher use of pain medication for neck pain throughout the trial’s observation period.”
“Our results suggest that SMT and HEA both constitute viable treatment options for managing acute and subacute mechanical neck pain.”
Additional findings include, 40% of the chiropractic adjustment patients and 46% of the home exercise/advice patients experienced an adverse event; 100% of these adverse events were musculoskeletal in nature and of short duration. In contrast, 60% of the drug patients experienced an adverse event, and 100% of these were of a more serious nature; they included:
1% increased blood pressure
1% stress incontinence
5% disturbed sleep
12% cognitive symptoms
12% dry mouth
20% gastrointestinal symptoms
Thus, the mechanical approaches to acute/subacute neck pain management were shown not only to be significantly more effective than medication, but also significantly safer.
Although the printed words in the article suggest that chiropractic spinal adjusting and home exercise/advice are essentially equal in the management of acute and subacute neck pain, a careful review of the measured markers presented in the article show that chiropractic adjustments were nearly always superior to those from home exercise/advice. As examples:
9 markers are listed for “Portion With Absolute Reduction In Pain“:
Spinal adjusting was superior in 8 of 9 of the listed markers.
6 markers are listed for “Pain Score“:
Spinal adjusting was superior in 5 of the 6 markers listed.
Additionally, a careful review of the charts presented in the article show that during the randomization, nearly twice as many of the chiropractic group (29.7%) had trauma initiated neck pain compared to the home exercise/advice group (16.5%). My clinical experience, which is extensive, has been that trauma triggered neck pain is always more difficult to manage in both the short and long term as compared to non-trauma triggered neck pain. It appears to me that the chiropractors had a tougher patient draw as compared to the home exercise /advice group. This finding was not discussed in the text of the article.
Although the article states several times that the chiropractic adjustments were given over a period of 12 weeks, the actual range of adjustments was 2-23 with a mean of 15.3. This is slightly more than 1 adjustment per week for 12 weeks. In my experience, acute neck pain responds best to daily treatment or at a minimum 3 times per week for a period of 2-3 weeks. I believe that an increase in the frequency of treatment by the chiropractors, as is commonly prescribed by many chiropractors, would have increased the chiropractic advantage over home exercise/advice.
Additionally, this article does not represent typical chiropractic clinical practice, which would usually include a greater range of management than spinal adjusting alone, often further improving clinical outcomes. Typical chiropractic clinical approaches to the management of pain syndromes would also include anti-inflammatory nutrition, low level laser therapy, traction, as well as home exercise/advice.
In contrast, the home exercise/advice group was seen only 1 or 2 times, but instructed to do neck exercises at home daily. The exercises consisted of 7 isolated maneuvers that required 3 different positions: sitting, supine head supported, and supine head unsupported. Each maneuver required 10 repetitions, and the patient was instructed to repeat all of the maneuvers 6-8 times per day. I performed the exercise maneuvers as prescribed and found that a session takes approximately 10 minutes.
Consequently, the authors are advocating that patients with acute/subacute neck pain exercise 60-80 minutes per day. I find this to be both impractical and unrealistic.
Consequently, I believe that for all of these reasons, chiropractic spinal manipulation (and chiropractic commonly employed adjuncts, including exercise/advice) is the most practical and effective management for acute/subacute neck pain.
Upper Cervical and Upper Thoracic Thrust Manipulation Versus Nonthrust Mobilization in Patients With Mechanical Neck Pain:
A Multicenter Randomized Clinical Trial
Journal of Orthopaedic & Sports Physical Therapy
January 2012; Volume 42; Number 1; pp. 5-18
James R. Dunning, Joshua A. Cleland, Mark A. Waldrop, Cathy Arnot, Ian Young, Michael Turner, Gisli Sigurdsson
Although there are significant differences between the various techniques employed by clinical chiropractic, chiropractic is best known for the inclusion of thrust manipulation of dysfunctional spinal joints resulting in audible joint cavitation. This study is a randomized clinical trial to compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude (HVLA) thrust manipulation to nonthrust mobilization in patients with neck pain. Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain, no studies have directly compared the effects of both upper cervical and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain.
In this study, 107 neck pain participants were evaluated subjectively and objectively, and then randomized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical (C1-2) and upper thoracic (T1-2) spines (n = 56) or nonthrust mobilization (n = 51).
The participants were reexamined 48-hours after the initial examination/treatment and again completed the outcome measures. The effects of treatment on disability, pain, C1-2 passive rotation range of motion, and motor performance of the deep cervical flexors were examined.
The patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly greater reductions in disability (50.5%) and pain (58.5%) than those of the nonthrust mobilization group (12.8% and 12.6%, respectively) following treatment. In addition, the HVLA thrust manipulation group had significantly greater improvement in both passive C1-2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization.
The authors concluded that the combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain.
The authors note that a bout 54% of individuals have experienced neck pain within the last 6 months. The economic burden associated with the management of patients with neck pain is high, second only to low back pain in annual workers’ compensation costs in theUnited States.
The C1-2 articulation has a high frequency of involvement in patients with neck pain and headaches. Disturbances in joint mobility in the upper thoracic spine may be an underlying contributor to musculoskeletal disorders in the cervical spine. Decreased mobility in the cervicothoracic junction (C7-T2) is associated with mechanical neck pain.
The primary outcome measure used in this study was the patient’s perceived level of disability as measured by the Neck Disability Index (NDI). The NDI is the most widely used condition-specific disability scale for patients with neck pain. The NDI has been demonstrated to be a reliable and valid outcome measure for patients with neck pain.
The authors state:
“A single session of HVLA thrust manipulation directed to both the upper cervical and upper thoracic spines results in greater improvements in disability, pain, atlantoaxial joint ROM, and motor performance of the deep cervical flexor muscles than nonthrust mobilization directed to the same regions.”
“We directed treatment to the atlantoaxial joints, because the C1-2 articulation has been found to have a high frequency of symptomatic involvement in patients with neck pain and headaches and previous studies have demonstrated that this articulation is where the majority of cervical rotation occurs.”
“The results of the current study demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation, experienced greater reduction in pain and disability, showed greater improvement in passive C1-2 rotation range of motion, and had greater increases in motor performance of the deep cervical flexor muscles, as compared to the group that received nonthrust mobilization at a 48-hour follow-up visit.”
“The combination of HVLA thrust manipulation procedures directed to both the upper cervical and upper thoracic articulations may enhance the overall outcomes of patients with mechanical neck pain.”
Nonthrust mobilization is not worthless; it clearly helped the patients in this study. However, thrust/cavitation manipulations of the same spinal regions (upper cervical and upper thoracic spines) were significantly superior to mobilization in:
1) Overall successful outcomes
2) Disability reduction
3) Pain reduction
4) Increased cervical range of motion
5) Improvements in motor performance of the deep cervical flexors
Also, this study indicates that upper cervical and upper thoracic spines are biomechanically functionally linked and that the superior results achieved in this study as compared to other studies is as a consequence of adjusting both regions.
The Chiropractic Impact Report™ is a monthly publication by myself, Dan Murphy, DC. I am a 1978 graduate ofWesternStatesChiropracticCollege inPortland,OR. I have managed about 10,000 whiplash-injury cases. In the past 32 years, I have taught more than 500 12-hour post graduate continuing education classes pertaining to whiplash and spinal trauma, including 21 years of coordinating a year-long certification program in spine trauma, certified through the International Chiropractic Association. Additionally, I am board certified in chiropractic orthopedics (DABCO), and I am on the faculty at Life Chiropractic College West inHayward,CA (28 years).
The purpose of The Chiropractic Impact Report™ is to keep you updated as to relevant academic concepts pertaining to whiplash-injured patients. The hope is that the information is useful in terms of enhanced understanding, as well as helping the personal injury attorney deal with insurance claim adjusters and adverse medical experts.
The chiropractor sending you this Report is well versed and trained in these concepts, and can be a valuable asset in personal injury cases in terms of both academics and treatment. Additionally, these expert chiropractors have access to a monthly phone consultation with me to discuss any pertinent issues that they may be facing on a particular case. I hope that you find this Report and the referring chiropractor a valuable resource.
Daniel J. Murphy DC, DABCO