Publisher'’s Note: In celebration of 40 years of Dynamic Chiropractic, I’ve asked some of the great leaders who have impacted our profession to write their own “Report of My Findings.” This month’s guest author is Scott Haldeman, DC, MD, PhD. At 80 years old this June, Dr. Haldeman is still heavily involved in changing health care. His recent paper on the comorbid relationship between back pain and major depression is set to open doors for chiropractic and will soon be followed by three more. He is also the driving force behind World Spine Care, which is taking chiropractic to remote areas of the world. I am proud to say he is a longtime friend, remains my mentor (and continues to make me feel lazy with all he does).
I have always wondered why chiropractors feel they are in competition with one another to attract patients. It does not make sense that chiropractic colleges in the United States (not in the rest of the world) have had difficulty attracting students.
Furthermore, it is not clear why chiropractors and physical therapists feel they are competing, sometimes fighting vicious political battles with the intention of reducing the availability of clinicians who are committed to evidence-based care of people suffering from and often disabled by spinal pain and related disorders.
Back Pain: Not Enough DCs in the U.S.
The U.S. National Bureau for Health Statistics reports that in 2019, 39.0% of adults (over 100 million people) had back pain in the prior three months. It also reports that the most vulnerable adults ages 65 and older, women, non-Hispanic white adults and those with income below 100% of the federal poverty level (FPL) were most likely to experience back pain.1
The number of chiropractors actively seeing patients in the U.S. is difficult to determine. The American Chiropractic Association estimates there are 70,000 graduate chiropractors in the US... On the other hand, the U.S. Bureau of Statistics reports that the number of chiropractic jobs, which presumably reflects those in practice, is 53,200.2
The difference in these numbers may be due to those graduates who have retired, are working part time, are in academic and administrative positions, or for other reasons are not seeing patients. This means there are approximately 2,000 people in the U.S. with low back pain for every practicing chiropractor.
There is considerable variation in the number of patients a chiropractor can treat each day or week, but many surveys suggest 100 patients a week (20 patients a day) is a reasonable average, with 7-9 new patients a week. The average number of treatments per patient also varies, but some surveys suggest nine treatments per episode of back pain is common.
This would suggest that a busy chiropractor could see a maximum of only 500 individual patients a year out of the 2,000 with low back pain who need care.
The Global Need Is Even Greater
Globally, the need for clinicians who can help patients with low back pain is much more serious. In 2015, over half a billion people worldwide had low back pain lasting more than three months duration. Low back pain and neck pain are the leading causes of years lived with disability in most countries and in most age groups.3
A survey of national chiropractic associations suggests there are only 103,000 chiropractors internationally, two-thirds of whom practice in the U.S.4 Even if not all chiropractors were included in this survey, this leaves less than 30,000-40,000 chiropractors available to provide care for the remaining 400 million people with low back pain in countries other than the U.S. The impact of the available chiropractors, if they only treated low back pain, would still be minimal in addressing this problem on a global scale.
The impact of spine-related symptomatology and disability is so great that it would take three times as many nonpharmaceutical / nonsurgical primary spine care clinicians in the U.S., and greater than 10 times as many worldwide, to provide care for patients, if the only goal was to reduce the health and disability burden of low back pain.
The Non-LBP Need Is Also High
Low back pain is, however, not the only reason patients seek the care of chiropractors. It is estimated that more than a third of a billion people globally have symptoms of neck pain lasting more than three months duration.3
The Bone and Joint Decade Task Force on Neck Pain5 and the Global Spine Care Initiative6 have reviewed the literature and recommended nonpharmaceutical / nonsurgical interventions for the management of neck pain and associated care commonly offered by chiropractors.
It is also very common for people to develop thoracic pain and to seek care, although there are no widely accepted databases to determine the prevalence of thoracic pain. In addition, there is increasing interest in and research investigating the impact of care commonly given by chiropractors for both cervicogenic and migraine headaches.5,7
These conditions in and of themselves require double the need for such care commonly offered by chiropractors.
There is growing evidence that providing manipulation as an initial choice of care for back and neck pain can reduce the prescription of opioids,8 with the possible, although not established, outcome of impacting the disability and cost of opioid dependency.
In addition, there is an increasing body of research that shows high-level comorbidity between spinal pain and a wide variety of nonmusculoskeletal diseases including depression, diabetes and hypertension.9-10
There is still no evidence that spinal manipulation as a sole treatment modality has any impact on non-MSK diseases. However, the comorbidity research raises the possibility that relieving the symptoms and disability associated with back pain could have a positive impact on patients with non-MSK diseases. If definitive research does demonstrate such an impact, then the demand for clinicians who are capable of treating spinal pain will increase further.
What’s Keeping Patients Away?
This raises the question as to why chiropractors continue to have to work hard to attract patients, especially in the U.S. One concern is the unwillingness of large portions of the chiropractic profession to identify the practice of chiropractic as primarily providing care directed at the relief of spinal pain, associated disability and related disorders.
There is also a significant proportion of the profession that is not familiar with or willing to accept the current evidence on the management of spinal disorders; and continue to make claims that are not compatible with currently published scientific literature.
This lack of identity and understanding of the role of chiropractic has markedly reduced the understanding of what a chiropractors is by patients and non-chiropractic clinicians; and reduced the confidence that going to a chiropractor will result in the provision of the most up-to-date, evidence-based treatment recommendation. This confusion by the public has greatly reduced the demand for the care chiropractors offer.
Steps in the Right Direction
The demand for a primary spine care clinician that patients and clinicians recognize and trust as the most highly trained, skilled and competent in providing the most up-to-date, evidence-based spine care is continuing to grow. The World Health Organization has recognized the extraordinary disability burden of back and neck pain, and is currently developing international guidelines for the management of low back pain.
The WHO has also constituted the World Rehabilitation Alliance with the goal of addressing the lack of resources and clinical personnel capable of reducing the disability crisis. Both the World Federation of Chiropractic and World Spine Care have been invited to participate in these initiatives.
These initiatives are anticipated to establish standards of care and markedly increase the demand for clinicians who can positively impact the burden of disability in this world.
The Big Question We Must Answer
The question is whether the chiropractic profession is willing and able to commit to the role of the primary spine care clinician and become the first clinician the public and other health professions feel is the most qualified and most capable doctor patients should see for spine-related symptoms or concerns.
If this is the role chiropractors are able to assume, there will be an unbelievable demand for more chiropractors globally; more patient demand for chiropractors than exist or can be trained in the foreseeable future; and no reason to be concerned about physical therapists and other health care professions that are working toward similar goals.
References
- Lucas JW, Connor EM, Bose J. “Back, Lower Limb and Upper Limb Pain Among US Adults in 2019.” NCHS Data Brief No. 415, July 2021.
- Occupational Outlook Handbook: Chiropractors. Bureau of Labor Statistics, U.S. Department of Labor: https://www.bls.gov/ooh/healthcare/chiropractors.htm (visited Jan. 18, 2023).
- Hurwitz EL, Randhawa K, Yu H, et al. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. Eur Spine J, 2018 Sep;27(Suppl 6):796-801.
- Stochkendahl MJ, Rezai M, Torres P, et al. The chiropractic workforce: a global review. Chiropr Man Therap, 2019;27:36. (2019).
- Haldeman S, Carroll LJ, Cassidy JD, et al. Executive summary: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 2008;33(4S):S5-S7.
- Haldeman S, Nordin M, Chou R, et al. The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities. Eur Spine J, 2018 Sep;27(Suppl 6):776-785.
- Rist PM, Hernandez A, Bernstein C, et al. The impact of spinal manipulation on migraine pain and disability: a systematic review and meta-analysis. Headache, 2019;59:532-542.
- Whedon JM, Toler AWJ, Kazal LA, et al. Impact of chiropractic care on use of prescription opioids in patients with spinal pain. Pain Med, 2020 Dec 25;21(12):3567-3573.
- de Luca K, Parkinson L, Haldeman S, et al. Association between spinal pain and comorbidities for women with self-reported spinal pain. JMPT, 2017;40:459-466.
- Yang H, Hurwitz EL, Li J, et al. Bidirectional comorbid associations between back pain and major depression in US adults. Int J Environ Res Public Health, 2023;20:4217. Read Here
