Ronald J. Farabaugh, DC
Since the inception of HPP, few treatment-related issues have stirred more controversy than chiropractic treatment for chronic pain. Due to the natural history of degeneration, some believe that at a certain point in time the obligation of the employer should stop and personal responsibility should begin for treatment of chronic pain. Others believe that since the work injury may have caused permanent damage that resulted in chronic pain, benefits should be paid for life. Both chiropractic and medical consultants have been criticized for improperly applying guidelines and denying necessary care. Field doctors have been criticized for poor documentation. Embedded somewhere in this HPP quagmire is the truth.
So, where and how does chiropractic fit in? This paper will suggest that properly managed chiropractic care can often be the treatment of choice for chronic back pain compared to the most commonly recommended alternatives, including drugs (NSAIDs) and exercise. This paper also will identify indications, contraindications and treatment guidelines for appropriate chiropractic management of chronic pain. Documentation issues (covered in many previous OSCA seminars), while mentioned, will be covered more thoroughly at a later time. Commonly assumed statements about chiropractic will serve as our guide through this paper.
"I thought soft-tissue injuries healed in 6-12 weeks. Why should we pay for chronic pain?"
One of the most common myths about back pain is that the majority of pain is "self-limiting" with a short and predictable healing time. While minor acute conditions heal in a timely and uncomplicated fashion, moderate to severe injuries usually heal with enough scar tissue to create residual soft-tissue weakness. These cases can be "complicated" and often result in chronic back pain.
A 1998 study in the British Medical Journal found that only 25 percent of patients consulting about the problem reported full recovery 12 months later. Seventy-five percent of acute low back pain (LBP) patients continue to endure chronic pain much longer than traditionally believed. The study further states, "We should stop characterizing low back pain in terms of multiplicity of acute problems, most of which get better and a small number of chronic long-term problems. Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations and recurrences."1
This research would seem to suggest that 75 percent of acute LBP patients continue to endure chronic pain much longer than traditionally believed. Numerous other studies have clearly demonstrated that the belief that all soft tissue injuries/sprains/strains are self-limiting with a healing time of 6-12 weeks is simply erroneous and archaic thinking. One study reported in Spine demonstrated that only 27 percent of patients were completely recovered in three months.2
"Are non-steroidal antiinflammatory drugs (NSAIDs) safe and effective to adequately control chronic pain?"
NSAIDs are still the most common types of substances used by millions who suffer from joint agony. They can certainly offer some relief for chronic-pain patients. These drugs, however, are linked to a broad spectrum of uncomfortable and even life-threatening side effects. They are known to induce a wide range of gastrointestinal problems when taken in high quantities and for long periods of time, and can harm the liver and cause kidney failure.3
Researchers also discovered that NSAIDs actually hasten the destruction of joints by inhibiting the synthesis of proteoglycans, vitally important molecules that attract water to cartilage.3 And the conclusion of another study on NSAIDs stated: "Unnecessary NSAID prescribing and suboptimal management of NSAID-related side effects were sufficiently common to raise questions about the appropriateness of NSAID use in the general population."4
Drugs classified as NSAIDs include aspirin, ibuprofen, and ingredients in Aleve, Naprox, Voltaren, Indocin and others. In addition to gastrointestinal (GI) bleeding, other side effects include ulceration, perforation and less commonly, hepatitis, asthma and tinnitus. Unfortunately, most people do not realize the extent of the danger. An article in The New England Journal of Medicine labeled the deaths caused by complications from these drugs a "silent epidemic," killing more than 16,000 people annually.5
The risks of adverse side effects as a result of NSAID use increases with prolonged use. Unfortunately, those suffering from chronic pain are also often the ones repeatedly reaching for relief through more and more drugs. While these drugs may be effective at relieving pain, they do not restore mobility and joint function.6 Given the high incidence of chronic pain experienced by injured workers, no doubt NSAID use and the associated risks are even greater in the Ohio Workers' Compensation system.
NSAID use for temporary pain relief becomes a vicious cycle. In the end, both the patient and the employer may lose to deteriorating joint stability and health, and poor work performance.
"Will home exercise and/or physical rehabilitation prevent the need for ongoing care?"
While exercise is an integral component of a well-managed overall treatment plan, it is not the panacea for the prevention or control of chronic pain, as many case managers and consultants would suggest. The plain truth is that based on clinical experience, most patients simply do not comply with exercise recommendations. Injured workers are not alone. How often do any of us regularly engage in stretching and strengthening exercises? We all know how important exercise is to maintain health, but the majority of Americans simply do not like exercise.
Every January, most gyms in America are full of well-intentioned "athletes" fulfilling their New Year's resolution. By March, the gym is usually reduced to the same dedicated few who will work out all year long. Injured workers are no different.
Even more important is the fact that some case managers "encourage" the injured worker into physical rehabilitation for a six-week program to hopefully "cure" the chronic patient. There is little to no research to support rehabilitation once the case has become chronic. Consider this scenario: Within six weeks of spending $5,000-$10,000 on a rehabilitation program, the majority of patients are likely to settle back into the same old routine, thus eliminating any gains made via rehabilitation. What happens when a person quits exercising? The same type of deconditioning can be expected when an injured worker ends a rehabilitation program and fails to comply with home exercise.
While the workers' compensation system spends thousands on rehabilitation programs, case managers are reducing chiropractic costs (usually 1-2 visits per month at a cost of less than $100) by fighting "supportive care" payments for chronic conditions. Does this make sense, especially when the patient is on the job working at the same job that caused his or her original injury and subsequent chronic pain? Exercise (home - directed or formalized rehabilitation programs), while important, is no long-term "cure."
Current research discovered that the popular McKenzie exercise program did not reduce recurrences or long-term utilization of health care.7,8 Can chiropractic play a role in the proper management of chronic conditions? And can chiropractic increase revenues of MCOs by keeping injured workers on the job?
Studies demonstrate that chiropractic care can return a worker to work in less time, with fewer costs and less disability!
Numerous scientific studies have supported the use of spinal manipulation in the treatment of chronic pain. In addition, studies from across the country have supported the fact that chiropractic manipulation can return a patient to work in less time, with less cost, and less disability compared to traditional medical care.
An Australian study concluded the following: "Comparison demonstrated that (I) a significant reduction was seen in the number of claimants requiring compensation days when chiropractic care was chosen, (II) fewer compensation days were taken by claimants who chose chiropractic care, (III) more patients progressed to chronic status when medical care was chosen and (IV) the average payment per claim was greater with medical management." The study further encourages increased utilization of chiropractic care and increased early referral of claimants with mechanical back pain by MDs to DCs.9
A study published in the Journal of Occupational Medicine found that (I) chiropractic care was 73 percent more cost-effective per case, (II) the average cost per office visit was 67 percent less for chiropractic than for a medical office visit, and (III) patients seeing doctors of chiropractic were able to return to work 10 times sooner than those under medical care.10
A University of Virginia study concluded that chiropractors see their patients more frequently, but have lower overall costs for most of the conditions considered. The researchers stated, "By every test of cost-effectiveness, the general weight of evidence shows that chiropractic provides important therapeutic benefits at economical costs."11
The MEDSTAT Project concluded that plans which have limited or no chiropractic coverage have the highest total costs per patient. Broader coverage of chiropractic services results in dramatically lower health care costs: 35 percent lower hospital admission rates; 42 percent lower inpatient payments; and 23 percent lower total health care costs.12
Another study examined 10,652 closed cases of patients with back-related injuries who were covered by Florida's workers' compensation law, to compare chiropractic case management with standard medical case management. Results indicated that the duration of temporary total disability was 51.3 percent shorter for chiropractic patients, the cost of chiropractic service was 58.8 percent lower, and 52.2 percent of medical patient claimants were hospitalized compared to only 20.3 percent of chiropractic patients.13
"What research supports the use of spinal manipulation for chronic back pain?"
A British 10-year study concluded that chiropractic treatment was significantly more effective, particularly with patients with chronic and severe pain.14 A second study appeared in the British Medical Journal in 1992, confirming the results of the first study. It concluded, "Manipulative therapy and physiotherapy are better than general practitioner and placebo treatment. Furthermore, manipulative therapy is slightly better than physiotherapy after 12 months."15
Despite exercise failing to cure back pain, exercise is still recommended in a quality treatment program. Current research demonstrates that continuance of exercise was associated with a better outcome along with other treatment options. "For the management of chronic back pain, trunk exercise in combination with manipulation or NSAIDs seems beneficial and worthwhile."16
Another study compared spinal manipulation, needle acupuncture and NSAIDs for the treatment of chronic back pain. After 30 days, spinal manipulation was the only intervention to achieve statistically significant improvement. Intervention by way of acupuncture or NSAIDs did not result in significant improvements in any of the outcome measures.17
A double-blind study of the efficacy of spinal adjustive therapy delivered by chiropractors was designed and implemented at the clinic of a chiropractic college. While the sampling was small, the results were clear and demonstrated the need for a larger scale study. It found that both subjectively and objectively, chiropractic therapy is more effective at relieving low back pain than a manual placebo treatment.18
A systematic review of randomized controlled trials in Spine found "strong evidence for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term results." Additionally, the study found that no single therapeutic intervention was demonstrated to be effective in the treatment of chronic LBP.19 Another study found in Spine supported the use of spinal manipulation for chronic low back pain. The study concluded, "[T]here appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks' duration."20
The benefit of chiropractic manipulation (in addition to exercise) over single intervention treatments such as acupuncture, exercise and NSAIDs for patients with chronic pain syndromes is clear and supported by scientific study. Manipulation is certainly the safest and most effective treatment to keep a spine functional and the chronic pain patient employed.
Editor's note: Part 2 of this article, scheduled to appear in the Oct. 22 issue of
DC, contains complete references for both parts. Part 2 addresses, among other topics, appropriate criteria for and documentation of, ongoing care.
