Is the Spine Care Mystery Finally Solved?

In the research world, low back pain has become the benchmark for effectiveness, as there are significantly more studies on LBP than any other musculoskeletal ailment. The studies we have seen over the past several years read like the makings of a great detective novel. But instead of trying to discover "who done it," science has been eliminating the usual suspects in an effort to unveil "who should do it."

Ruling Out PTs or DOs

A study published last August eliminated two professions from the lineup. The randomized, controlled trial revealed that "[neither] spinal manipulation nor mobilization appeared to be an effective intervention for young adults with mild to moderate chronic low back pain." While this may be unsettling on its face, it should be noted that "all treatments" were provided by "either a doctor of osteopathic medicine or physical therapist."^1-2

It's Not MDs, Either

The most recent study (see the top story in this issue) narrows down the virtual last profession standing. In their efforts to better understand the risks associated with patients' transition from acute to chronic LBP, the research team at the University of Pittsburgh discovered that almost half (48 percent) of medical patients received "nonconcordant care" based upon the current guidelines. The researchers' work demonstrated that "exposure to nonconcordant care was associated with increased odds of developing chronic LBP."³

In essence, the nonconcordant care provided by the medical physicians during the first 21 days of care increased the patient's chances of transitioning from acute to chronic. Not surprisingly, the most common form of nonconcordant care involved drugs. Almost a third, (30 percent) "received prescriptions for nonrecommended medications," of which almost two-thirds (65 percent) received opioids.

Health Payers Are Noticing

The above is not lost on health payers, who enjoy the ability to analyze large data to better understand what works. Two years ago, David Elton, DC, senior VP of clinical programs at OptumHealth, gave a powerful presentation in which he outlined the most effective care for their insureds. Dr. Elton noted, "The pathway that's most aligned with all prevailing guidelines [is] when patients start with chiro / PT / acupuncture. ... You receive the services you should, you avoid the services you shouldn't, imaging is aligned, total episode cost is lowest. ... The actuaries have done the work, it's presented at the actuarial conference, the net of the increased conservative care will take out about 230 million in annual medical expenditures and reduce opiate prescribing for back pain by 25-26 percent."^4-5

The Last Profession Standing: But Why Aren't We Being Recognized?

So, what's the problem? Why aren't almost all acute spine cases seen by DCs? (Not that this is the only benefit to chiropractic care.)

More than 30 years ago, United States District Judge Susan Getzendanner held that "the conduct of the AMA and its members constituted a conspiracy in restraint of trade based on the following facts: the purpose of the boycott was to eliminate chiropractic; chiropractors are in competition with some medical physicians; the boycott had substantial anti-competitive effects; there were no pro-competitive effects of the boycott; and the plaintiffs (chiropractors) were injured as a result of the conduct." Old prejudices die hard. I believe the impact of this effort is still influencing referral decisions today.⁶

Based on these and multiple earlier studies, chiropractic is the only profession left standing for effective LBP care, both acute and chronic. And while this distinction minimizes the impact chiropractic care has on the rest of the spine, the entire musculoskeletal system and ultimately, total wellness, it does present providers and payers with a clear choice.

But as this most recent study demonstrates, many providers, particularly medical doctors, are still choosing nonconcordant care in place of guideline-directed chiropractic care. This suggests the battle for understanding and referral may also need to be fought in the trenches, with DCs reaching out to their local medical providers in an effort to educate them and facilitate an appreciation for just how effective chiropractic can be – particularly given the alternatives.

References

1. "PTs and DOs Are Lousy at Spinal Manipulation." Dynamic Chiropractic, Oct. 1, 2020.
2. Thomas JS, Clark BC, Russ DW, et al. Effect of spinal manipulative and mobilization therapies in young adults with mild to moderate chronic low back pain: a randomized clinical trial. JAMA Netw Open, 2020;3(8):e2012589.
3. Stevans JM, Delitto A, Khoja SS, et al. Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Netw Open, 2021;4(2):e2037371.
4. "Putting Spine Care in the Right Hands." Dynamic Chiropractic, March 1, 2019.
5. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. National Academies of Sciences, Engineering and Medicine, 2019.
6. More information can be found in Contain and Eliminate: The American Medical Association's Conspiracy to Destroy Chiropractic: https://www.dynamicchiropractic.com/book/.

Read more findings on my blog: http://blog.toyourhealth.com/ wrblog. You can also visit me on Facebook and Twitter (donpetersenjr, @donaldpetersen).