When we consider mechanical spine issues, we need to consider problems exclusive of fracture, tumor
or infection. According to Houweling Et. Al. (2015) back pain effects 43% of the population over the
course of a year. In addition, 33% of that group reported that their symptoms led to reduced
productivity at work. In Switzerland, this accounted for 3% of their gross domestic products and equates
to $14 Billion in US dollars. Chiropractic’s forte` and focus historically has been mechanical spine issues
and when considering who the first provider that should be consulted, one needs to examine the
scientific evidence based upon outcomes so that rhetoric has no place in utilization and the facts control
the argument and direction of the patient.
Simply put, where should a patient go first because it has been proven conclusively that it is the best
place to get better. From an insurance carrier and legislative perspective, the question goes one step
further and examines the cost of care and wheat is the best solution in a cost-effective care-path
realizing that often the government is the insurer or risk taker and even private carriers have a fiduciary
responsibility to their stockholders to ensure a profitable return, while offering the best possible
solutions for their insureds.
Day Et. Al. (2007) reported that only 26% of fourth year Harvard medical students had a cognitive
mastery of physical medicine (pg. 452). Schmale (2005) reported “Incoming interns at the University of
Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a
survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of
students tested failed to show basic competency. Perhaps the poor knowledge base resulted from
inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine
education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools
require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and
nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2%
of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of
primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors
have described shortcomings in medical student training in fracture care, arthritis and rheumatology,
and basic physical examination of the musculoskeletal system (pg. 251).
With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in
spine care, particularly of biomechanical [Subluxation] orientation, the question becomes which
profession has the educational basis, training and clinical competence to manage these cases? Let’s
take a closer look at chiropractic education as a comparison. Fundamental to the training of doctors of
chiropractic according to the American Chiropractic Association is 4,820 hours (compared to 3,398 for
physical therapy and 4,670 to medicine) and receive a thorough knowledge of anatomy and physiology.
As a result, all accredited doctor of chiropractic degree programs focus a significant amount of time in
their curricula on these basic science courses. So important to practice are these courses that the
Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education
requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation,
treatment and management.” In addition to multiple courses in anatomy and physiology, the typical
curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics,
orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this
basic science information for many hours prior to beginning clinical services in their internship.
To qualify for licensure, graduates of chiropractic programs must pass a series of examinations
administered by the National Board of Chiropractic Examiners (NBCE). Part one of this series consists of
six subjects, general anatomy, spinal anatomy, physiology, chemistry, pathology and microbiology. It is
therefore mandatory for a chiropractor to know the structure and function of the human body as the
study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education. As
a result, the doctor of chiropractic is expert in the same musculoskeletal genre that medical doctors are
poorly trained in their doctoral education as referenced above.
A 2005 study byDeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies
(neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms.This study
validates the reasoning behind the later study that people with severe muscle spasms in the low back
respond well to chiropractic care and this prevents future problems and disabilities. It also dictates that
care should not be delayed or ignored due to a risk of complications.
The above statistic indicates that while medicine cannot conclude an accurate diagnosis in 85% of their
back pain patients, chiropractic has already helped 87% of the same population. We also know that
chiropractic is one of the safest treatments currently available in healthcare for spinal treatment and
when there is a treatment where the potential for benefits far outweighs any risk, it deserves serious
consideration. Whedon, Mackenzie, Phillips, and Lurie(2015) based their study on 6,669,603 subjects
after the unqualified subjects had been removed from the study and accounted for 24,068,808 office
visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal
healthy tissues has been identified”(p. 5).
Houweling Et. Al (2015) concluded “Patients who initially consulted with MDs were significantly less
likely to be satisfied with the care received and the results of care compared with those who initially
consulted DCs” (p. 480) and Adjusted mean costs per patient were significantly lower in patients
initiating care with DCs compared with those initiating care with MDs. (p.480) “The findings of this study
pertaining to patient satisfaction were in line with previous research comparing chiropractic care to
medical care for back pain, which found that chiropractic patients are typically more satisfied with the
services received than medical patients.” (p.481)
Houweling Et. Al (2015) continued “Mean total spinal, hip, and shoulder pain-related health care costs
per patient during the 4-month study period were approximately 40% lower in patients initially
consulting DCs compared with those initially consulting MDs. The reason for this difference was a lower
use of health care services other than first-contact care in patients initially consulting DCs compared
with those initially consulting MDs. Previous observational studies comparing medical and chiropractic
care in terms of health care costs per patient have shown opposing results. Two studies conducted in
the United States found that patients with low back pain treated in chiropractic clinics incurred higher
costs than patients treated in medical clinics. One possible reason for these opposing findings is that
differences were brought about by the methods of determining costs. In the studies conducted in the
United States, costs were determined by chart audit, whereas in the present study, cost determinations
were based on an insurance database review of all health care services used for the conditions
investigated including the cost of visits to other health care providers.” Pg. 481
Perhaps the most telling point of Houweling Et. Al (2015) results were “Restrictive models of care in
which patients are required to contact a medical provider before consulting a chiropractic provider may
be counterproductive for patients experiencing the musculoskeletal conditions investigated and possibly
others. In addition to potentially reducing health care costs, direct access to chiropractic care may ease
the workload on MDs, particularly in areas with poor medical coverage and hence enabling them to
focus on complex cases. The minority of patients with complex health problems initially consulting a
chiropractic provider would be referred to, or co-managed with, a medical provider to provide optimal
care. (p.481)
The above model not only suggests, but verifies that chiropractic should be the first choice or the
primary spine care provider freeing up an already overburdened medical primary care provider’s office
where they are not qualified to manage mechanical spine issues as reported above. This also helps
resolve some of the issues in more rural regions where there is a shortage of primary care medical
providers and positions the public to realize better outcomes and serves the insurers by ensuring lower
costs.
References:
Houweling, T, Braga A., Hausheer T., Vogelsang M., Peterson C., Humphreys K. (2015) First-Contact Care
with a Medical vs. Chiropractic Provider After Consultation with a Swiss Telemedicine Provider:
Comparison of Outcomes, Patient Satisfaction, and Health Care Costs in Spinal, Hip, and Shoulder Pain
Patients, Journal of Manipulative and Physiologic Therapeutics, 38(7), 477-483
Day C., Yeh A., Franko O., Ramirez M., Krupat E. (2007) Musculoskeletal Medicine: An Assessment of the
Attitudes of Medical Students at Harvard Medical School, Academic Medicine 82: 452-457
DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity
of paraspinal muscles: A descriptive study.Journal of Manipulative and Physiologic Therapeutics, 28(7),
465-471.
Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated
with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4),
264-270.
