Disabling low back Oregon workers' compensation claims. Part III: Diagnostic and treatment procedures and associated costs.

Claimants in Oregon with disabling low back injuries attending chiropractors were found to have more treatments over a longer duration and at greater cost than claimants attending medical physicians with similar clinical presentations. These findings are attributed to: a) a higher proportion of chiropractic claimants than medical physician claimants with low back risk factors which may have adversely affected the course of recovery (chronic or recurrent low back conditions, obesity, extremity symptomatology, frequency of exacerbations); b) differences in age and gender of DC and MD claimants; c) the greater physician-patient contact hours characteristic of chiropractic practice; d) differences in therapeutic modalities employed; and e) the physician reimbursement permitted under Oregon workers' compensation law. The findings of this study emphasize the need for prospective studies of treatment outcome.     

Diagnostic Imaging in Chiropractic Practice: A Survey of Opinions and Self-Reported Guideline Adherence of Dutch and Belgian Chiropractors

ObjectivesThe purpose of this study was (1) to describe diagnostic imaging in Dutch and Belgian chiropractic practice in general, (2) to estimate adherence to the diagnostic imaging guidelines for patients with low back pain (LBP) via vignettes, and (3) to evaluate factors associated with diagnostic imaging and adherence to the guidelines.MethodsWe used a web-based survey to collect sociodemographic data, practice characteristics, amount of imaging, opinions, and indications for requesting imaging from registered Dutch and Belgian chiropractors in 2013. Additionally, adherence to imaging guidelines for LBP was assessed by 6 vignettes in patients with LBP. Multivariable regression analyses were conducted to explore associations between characteristics of chiropractors and the use of imaging. Generalized mixed models were used to explore guidelines adherence and their relationship with chiropractor's characteristics.ResultsThe overall response rate was 60% (n = 203 out of 340). In total, 83% of chiropractors viewed diagnostic imaging in general as an important part of their practice. It is important to note that Dutch and Belgian chiropractors are not allowed to refer directly for imaging. Chiropractors reported that they would like to have imaging in 42% of their patients. Imaging had already been performed in 37% of patients before the first visit and was ordered by another health care provider (ie, general practitioner or medical specialist). The most common indication for ordering imaging was exclusion of contraindications (73%). The most common reason against imaging was the perceived limited value (45%). Many chiropractors (71%) were familiar with imaging guidelines. Adherence to the imaging guidelines for LBP based upon the vignettes was 66%. Dutch chiropractors and chiropractors with less than 10 years in practice demonstrated better adherence to guidelines and imaging use as compared with Belgian and those with more than 10 years of experience.ConclusionsMost Dutch and Belgian chiropractors reported that imaging in general was important in chiropractic practice. Self-reported indications for ordering diagnostic imaging were in line with the imaging guidelines in the majority of cases. We found some variances between Belgian and Dutch chiropractors and years of experience related to guideline adherence.     

Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study

ObjectiveSpinal manipulation (SM) is recommended for first-line treatment of patients with low back pain. Inadequate access to SM may result in inequitable spine care for older US adults, but the supply of clinicians who provide SM under Medicare is uncertain. The purpose of this study was to measure temporal trends and geographic variations in the supply of clinicians who provide SM to Medicare beneficiaries.MethodsMedicare is a US government–administered health insurance program that provides coverage primarily for older adults and people with disabilities. We used a serial cross-sectional design to examine Medicare administrative data from 2007 to 2015 for SM services identified by procedure code. We identified unique providers by National Provider Identifier and distinguished between chiropractors and other specialties by Physician Specialty Code. We calculated supply as the number of providers per 100 000 beneficiaries, stratified by geographic location and year.ResultsOf all clinicians who provide SM to Medicare beneficiaries, 97% to 98% are doctors of chiropractic. The geographic supply of doctors of chiropractic providing SM services in 2015 ranged from 20/100 000 in the District of Columbia to 260/100 000 in North Dakota. The supply of other specialists performing the same services ranged from fewer than 1/100 000 in 11 states to 8/100 000 in Colorado. Nationally, the number of Medicare-active chiropractors declined from 47 102 in 2007 to 45 543 in 2015. The count of other clinicians providing SM rose from 700 in 2007 to 1441 in 2015.ConclusionChiropractors constitute the vast majority of clinicians who bill for SM services to Medicare beneficiaries. The supply of Medicare-active SM providers varies widely by state. The overall supply of SM providers under Medicare is declining, while the supply of nonchiropractors who provide SM is growing.     

Chiropractic in British Columbia: sociopolitical and clinical considerations for strategic planning

Findings from a major study of chiropractic in British Columbia are used to illustrate the nature of limitations that should be considered in planning chiropractics future direction. Fifty chiropractors, 60 new clients of chiropractors and selected leaders of the chiropractic profession were interviewed on a variety of issues. Results indicate that sociopolitical factors limiting chiropractic include lack of access to public facilities, absence of representation in government services, lack of public funds for research and education, limits to reimbursement for services and low social valuation. Nine findings are identified as critical to future organizational plans. We suggest that a specific planning approach, such as the critical success factor (CSF) approach, be considered as a planning framework for organizational success in complex sociopolitical environments.     

Association Between Characteristics of Danish Chiropractors and Number of Referred Patients From General Practitioners: A Cross-sectional Study

ObjectiveThe purposes of this study were to quantify the number of patients referred weekly from primary health care general practitioners (GPs) to chiropractors and to identify chiropractor characteristics associated with the number of referrals.MethodsAn online, cross-sectional survey was sent to the 600 active members of the Danish Chiropractic Association. Of those, 364 completed the survey and 286 met our inclusion criteria. We used bivariable analyses and negative binomial multivariable regression to evaluate the association between predetermined characteristics and the weekly number of patients referred by GPs.ResultsOn average, chiropractors reported that they received 2.5 (standard deviation, 2.2) referrals from GPs per week, representing 31% of all new patients received by chiropractors. Clinics with more than 1 chiropractor and access to diagnostic ultrasound received more GP referrals. Chiropractors reporting expertise in geriatrics and a higher number of new patients per week reported more referrals. Chiropractors who reported referring more patients to GPs also reported receiving more referrals from them.ConclusionVariables related to access to chiropractic care, the type of care provided, and interprofessional communication were positively associated with the number of GP referrals that chiropractors self-reported. This is the first study to report on factors associated with GP referrals to Danish chiropractors.     

Economies of scope and payment for physician services.

Physician payment reform will base payment largely upon physician work. Current reforms assume that services are provided independently, yet physicians may often perform two or more services at one time. There is evidence from other industries that services provided jointly may not require the same total resources as identical services provided independently. This study evaluated whether physician-reported work and time were the same for some common services when provided jointly and when provided separately. Six case vignettes were constructed consisting of two services each. Forty-four general internists rated the total work and time required for each vignette performed as a whole, and for the two services performed separately. Total work was estimated using a magnitude estimation technique similar to that used in developing the resource-based relative value scale. For five of the six vignettes, the work rating for performing the services together was significantly less than the sum of the ratings for the separate services. The work savings associated with providing services together ranged from 4% to 30% of the total work of the separate services. A similar reduction was observed for the estimated time to perform services jointly in four of the six vignettes. In no case was work or time lower when services were provided separately. Physicians report lower work and time for at least some pairs of services, compared with providing the same services separately. Reimbursement mechanisms that fail to account for these reductions may provide incentives to combine or add services.     

Chiropractic: a critical evaluation

Chiropractic was defined by D.D. Palmer as “a science of healing without drugs.” About 60,000 chiropractors currently practice in North America, and, worldwide, billions are spent each year for their services. This article attempts to critically evaluate chiropractic. The specific topics include the history of chiropractic; the internal conflicts within the profession; the concepts of chiropractic, particularly those of subluxation and spinal manipulation; chiropractic practice and research; and the efficacy, safety, and cost of chiropractic. A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews. Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today. Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.     

An Investigation of Chiropractor-Directed Weight-Loss Interventions: Secondary Analysis of O-COAST

ObjectiveThe purpose of this study was to investigate weight-loss interventions offered by Canadian doctors of chiropractic to their adult patients.MethodsThis paper reports a secondary analysis of data from the Ontario Chiropractic Observation and Analysis STudy (N_c = 42 chiropractors, N_p = 2162 patient encounters). Multilevel logistic regression was performed to assess the odds of chiropractors initiating or continuing weight management interventions with patients. Two chiropractor variables and 8 patient-level variables were investigated for influence on chiropractor-directed weight management. In addition, the interaction between the effects of patient weight and comorbidity on weight management interventions by chiropractors was assessed.ResultsAround two-thirds (61.3%) of patients who sought chiropractic care were either overweight or had obesity. Very few patients had weight loss managed by their chiropractor. Among patients with body mass index equal to or greater than 18.5 kg/m², guideline recommended weight management was initiated or continued by Ontario chiropractors in only 5.4% of encounters. Chiropractors did not offer weight management interventions at different rates among patients who were of normal weight, overweight, or obese (P value = 0.23). Chiropractors who graduated after 2005 who may have been exposed to reforms in chiropractic education to include public health were significantly more likely to offer weight management than chiropractors who graduated between 1995 and 2005 (odds ratio 0.02; 95% CI [0.00-0.13]) or before 1995 (odds ratio 0.08; 95% CI [0.01-0.42]).ConclusionThe prevalence of weight management interventions offered to patients by Canadian chiropractors in Ontario was low. Health care policy and continued chiropractic educational reforms may provide further direction to improve weight-loss interventions offered by doctors of chiropractic to their patients.     

Chiropractic adjustment in the management of visceral conditions: a critical appraisal.

OBJECTIVE: To establish whether Australian chiropractors regard spinal adjustment as an intervention option for patients presenting with visceral conditions and to ascertain the preferred level of adjustment for patients presenting with migraine, asthma, hypertension or dysmenorrhea. DESIGN AND SETTING: A survey of all chiropractors registered in Australia. OUTCOME MEASURE: Practitioners' opinions regarding the usefulness of spinal adjustment in the management of patients with visceral conditions were canvassed. Based upon their personal clinical experience, practitioners were requested to comment on the appropriate level of adjustment in the management of various visceral conditions. MAIN RESULTS: Twenty-two percent of the 1311 chiropractors registered in Australia responded to the survey. More than half of the respondents favored a role for spinal adjustment in the management of patients with visceral conditions. The perceived usefulness of spinal adjustment varied according to the condition being managed, as did the preferred level of adjustment. CONCLUSIONS: Chiropractors continue to use spinal adjustment in the management of visceral conditions despite this intervention being regarded as an obstacle to the recommendation of public finding for chiropractic services in Australia. Further investigation into the validity of the chiropractic management of visceral conditions is recommended.     

Chiropractic and a new taxonomy of primary care activities

OBJECTIVE: To specify the procedural and cognitive content of primary care and to discuss potential chiropractic primary care roles. Data Collection: Data were collected through use of two expert panels and a consensus process to create a list of primary care activities. The first panel was an interdisciplinary mix of physicians, mainly allopathic ones; most of the members of the second panel were chiropractors. Each panel rated primary care activities across a number of dimensions, such as importance for good health, frequency in a typical office-based practice, necessity for medical doctor involvement in the activity, competence of the majority of chiropractic physicians, and interest among chiropractors in performing the activity. RESULTS: There was no real difference between the panels in terms of taxonomy scope or importance of the activities for good health. Many of the activities are performed more frequently in a typical medical office than in a typical chiropractic office. With respect to a set of primary care activities that occur daily in medical offices, chiropractors are able to make diagnoses in 92% of the activities and to make therapeutic contributions in more than 50% of the activities. Medical doctor involvement was perceived as required more frequently by the chiropractic panel than by the interdisciplinary panel. Moreover, chiropractors' interests and self-assessments of competence showed some limits with regard to their assumption of total care for some frequently occurring primary care activities. CONCLUSIONS: The most important finding of this activity is the overriding sense of agreement between allopathic and chiropractic physicians in terms of the scope of primary care activities, suggesting that there is opportunity for chiropractors and medical doctors to work together on patient care and organizational strategy. However, the levels of self-assessed competence and interest on the part of chiropractors for many frequently occurring primary care activities reveal some important limits for assumption of total primary care.     

Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Abstract

Use of manual therapy in the form of manipulation and massage is evident in the earliest recordings of history. Today, manual therapy is an evidence-based practice that can be used with predictable results in the treatment of a variety of neuromusculoskeletal problems. However, for some manual therapists, treatment is still based on a belief system that incorporates vitalism, energy healing, and other metaphysical concepts. Cooperation of practitioners in researching the effects of manual therapy would require uniformity based upon the guidelines of science, following rules for selection of an evidence-based therapy that produces predictable and replicable results. Such an approach would not allow contamination by dogma or by an agenda that is designed more to support a belief system than to find the truth. The chiropractic profession, which began with a founding father in 1895, is identified primarily by its use of manipulation. But chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words "manipulation" and "subluxation" in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial dislocation or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic "spinal lesion" that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is "adjusted" by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/ mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias.     

A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: part I

OBJECTIVE: To investigate the primary care, health promotion activities associated with what has historically been called "maintenance care" (MC) as used in the practice of chiropractic in the United States. This includes issues such as investigating the purpose of MC, what conditions and patient populations it best serves, how frequently it is required, what therapeutic interventions constitute MC, how often it is recommended, and what percent of patient visits are for prevention and health promotion services. It also investigates the economic impact of these services. DESIGN: Postal survey of a randomized sample of practicing US chiropractors. The questionnaire was structured with a 5-point ordinal Likert scale (28 questions) and brief fill-in questionnaire (12 questions). The 40-question survey was mailed to 1500 chiropractors selected at random from a pool of chiropractors with active practices in the United States. The National Directory of Chiropractic database was the source of actively practicing chiropractors from which doctor selection was made. The sample was derived by using the last numbers composing the zip codes assigned by the US Postal Service. This sampling method assured potential inclusion of chiropractors from all 50 states, from rural areas and large cities, and assured a sample weighting based on population density that might not have been afforded by a simple random sample. RESULTS: Six hundred and fifty-eight (44%) of the questionnaires were completed and returned. US chiropractors agreed or strongly agreed that the purpose of MC was to optimize health (90%), prevent conditions from developing (88%), provide palliative care (86%), and minimize recurrence or exacerbations (95%). MC was viewed as helpful in preventing both musculoskeletal and visceral health problems. There was strong agreement that the therapeutic composition of MC placed virtually equal weight on exercise (96%) and adjustments/manipulation (97%) and that other interventions, including dietary recommendations (93%) and patient education about lifestyle changes (84%), shared a high level of importance. Seventy-nine percent of chiropractic patients have MC recommended to them and nearly half of those (34%) comply. The average number of recommended MC visits was 14.4 visits per year, and the total revenue represents an estimated 23% of practice income. CONCLUSIONS: Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.     

The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy

OBJECTIVE: To investigate the frequency and types of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy. DESIGN: Retrospective information obtained by chiropractors through standardized interview of patients on return visit within 2 weeks of previous treatment. SETTING: The private practice of 87 Swedish chiropractors (response rate 81%). SUBJECTS: Twenty consecutive (presumably naive) patients per chiropractor (1504 valid questionnaires returned, 86% of optimal number of replies). INTERVENTION: Spinal manipulation with or without additional therapy provided by chiropractors. MAIN OUTCOME MEASURES: Self-reported improved nonmusculoskeletal symptoms (reactions). RESULTS: At least I reaction was reported after the previous treatment in 21% to 25% of cases. Of these responses, 26% were related to the airway passages (usually reported as "easier to breathe"), 25% were related to the digestive system (mostly reported as "improved function"), 14% were classified under eyes/vision (usually reported as "improved vision"), and 14% under heart/ circulation (about half of these reported as "improved circulation"). The number of spinal areas treated was positively associated with the number of reactions. CONCLUSION: A minority of chiropractic patients report having positive nonmusculoskeletal reactions after spinal manipulative therapy but such reports cluster predominantly around specific symptoms. It would be interesting to find out if these can be verified objectively and, if so, to investigate if they are caused by the treatment or if they are signs of natural variations in human physiology.     

Medicaid participation by medical and surgical specialists

Most studies of physician participation in Medicaid have focused on primary care physicians, but access by the poor to specialists' services is also a policy concern. This study examined Medicaid participation rates for a national sample of 2291 private practice physicians in nine medical and surgical specialties. Four fifths of the specialists treated at least some Medicaid patients, with an average case load of 11.2% Medicaid patients, rates very similar to those obtained elsewhere for primary care physicians. Surgical specialists, especially ophthalmologists, otolaryngologists, and urologists, were the most willing to participate, and cardiologists were the least willing. Multivariate analysis confirmed the importance of Medicaid programmatic characteristics on both physician entry and level of participation. A 10% increase in the Medicaid fee would raise specialist participation by 3%. Other factors encouraging participation included faster claims processing, fewer limits on the quantity of services covered, and more generous eligibility criteria.     

A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States

Abstract

Joint manipulation is an ancient art and science that can trace its origins to the earliest medical and lay practitioners. Today, it is practiced principally by physical therapists and chiropractors and to a lesser degree, by osteopathic and medical physicians. Self-manipulation of both joint and soft tissues is also a common practice in those who “crack” their own knuckles and spines. This article traces the history and development of manipulation from its origins to the present with a special emphasis on developments in the United States as a background for understanding current licensure and practice issues.

Since the beginning of this century, physical therapy has enjoyed a close relationship with medicine and has developed its knowledge base and practice in spinal and extremity manipulation from the medical profession. Manipulation in physical therapy has become a significant part of its rehabilitation practice, often encompassed in the terms therapeutic exercise, active and passive movement, or manual therapy. Instruction in manipulation begins with pre-professional education; for those who wish to specialize in this field, instruction continues at the post-professional level, following the medical model of specialization. Since the 1960's, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function.

By contrast, since its independent origins in the late 19th century, chiropractic has practiced manipulation for most of its history as a primary therapeutic tool to correct spinal subluxation. It provides spinal adjustments to facilitate the free flow of nerve energy, which, in turn, relieves many human ailments. Unlike physical therapy, chiropractic has not been practiced in cooperation with medicine but has existed as an alternative during most of its history. In recent years, the chiropractic profession has divided along philosophical lines: those who strongly defend the subluxation theory (straights) to those who do not (mixers), with the later group now holding sway. This change in chiropractic philosophy and practice has brought practitioners into a practice model more closely aligned with the comprehensive model of rehabilitation therapy modeled by physical therapists. Consequently, many chiropractors now use physical therapy procedures even though they are prohibited from calling themselves physical therapists. As a result, competition in the market place has heightened, with concomitant licensure and political challenges.

This article discusses the history and evolution of the practice of manipulation against a background of other key developments in health care; as such, it should provide understanding for today's current practice scene.     

Expectations of chiropractic treatment: what are the expectations of new patients consulting a chiropractor,and do chiropractors and patients have similar expectations?

BACKGROUND: There are conflicting views about whether expectation plays a role in patient satisfaction. No studies regarding the importance of patient expectations have been done in the chiropractic field. OBJECTIVE: To investigate the expectations of new patients consulting a chiropractor and to evaluate differences and similarities in expectations between chiropractors and patients. DESIGN: A questionnaire survey. STUDY PARTICIPANTS: Thirty chiropractors and 336 patients from 17 private practices throughout Sweden. RESULTS: Chiropractors and patients expected the chiropractor to find the problem and explain it to the patients, and they also expected patients to feel better and become free of symptoms. However, the following differences were revealed: patients had lower expectations of the chiropractic treatment than the chiropractors but higher expectations of being given advice and exercises than the chiropractors did. There was also a tendency for the patients to expect to get better faster than the chiropractors expected them to. CONCLUSION: Although chiropractors and patients had some common goals in relation to the therapeutic encounter, there was also a mismatch in certain areas. It is possible that these differences in expectations could influence the treatment and outcome of the treatment negatively. This reinforces the importance of communication between the chiropractor and the patients. More research is needed to evaluate whether fulfilment of expectations actually has an impact on patient satisfaction.