The Importance of the Initial Provider for Spine Care

Considerations for Costs, Outcomes, Surgery, Injections, and Imaging

Introduction

Healthcare providers of various disciplines tend to believe in and offer patients the intervention of their specialty:

• Medical doctors tend to prescribe medicines.
• Surgeons tend to offer surgery.
• Acupuncturists tend to offer needles.
• Massage therapists tend to offer massage.
• Physical therapists tend to offer physical therapy.
• Chiropractors tend to offer adjustments (specific line-of-drive manipulation).
• Etc.

Often, the initial provider for an ailment is the only provider ever seen for that ailment. It is quite rare for a patient to switch provider types. These biases can affect clinical outcomes and costs. Fortunately, these biases are being understood by our healthcare system. Their findings are quite good for the chiropractic profession.

Low Back Considerations

In 1977, Samuel Turek, MD, was a clinical professor in the Department of Orthopedics and Rehabilitation at the University of Miami School of Medicine. That year, the third edition of his book, Orthopaedics, Principles and Their Applications was published. It was an incredible work, comprising 1,574 pages (1).

In his book, Dr. Turek has a section titled:

Treatment of Intervertebral Disc Herniation with Manipulation

This section states:

“Manipulation. Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc. This treatment is regarded as controversial and a form of quackery by many men. However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery. Occasionally, the results were dramatic.”

“Technique. The patient lies on his side on the edge of the table facing the surgeon, and the uppermost leg is allowed to drop forward over the edge of the table, carrying forward that side of the pelvis. The uppermost arm is placed backward behind the patient, pulling the shoulder back. The surgeon places one hand on the shoulder and the other on the iliac crest and twists the torso by pushing the shoulder backward and the iliac crest forward. The maneuver is sudden and forceful and frequently is associated with an audible and palpable crunching sound in the lower back. When this is felt, the relief of pain is usually immediate. The maneuver is repeated with the patient on the opposite side.”

“The patient should be cautioned beforehand that the manipulation may make his symptoms worse and that this is an attempt to avoid surgery.”

••••

In 1985, William H. Kirkaldy-Willis, MD, was a Professor Emeritus of orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada. That year, he published an article titled (2):

Spinal Manipulation in the Treatment of Low Back Pain

In this article, Dr. Kirkaldy-Willis presents the results of 283 patients who were suffering from chronic low back and leg pain and treated with chiropractic spinal adjusting (specific line-of-drive manipulation). All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled (“constant severe pain; disability unaffected by treatment”).

Patient outcomes were graded as “good” if they achieved these results:

• Symptom-free with no restrictions for work or other activities.
• Mild intermittent pain with no restrictions for work or other activities.

81% of the patients with referred pain syndromes achieved the “good” result. 48% of the patients with nerve compression syndromes, primarily subsequent to disc lesions and/or central canal spinal stenosis, achieved the “good” result. No patients were made worse by the chiropractic joint adjusting. The authors made these statements:

“Spinal manipulation, one of the oldest forms of therapy for back pain, has mostly been practiced outside of the medical profession.”

“Over the past decade, there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.”

“Most family practitioners have neither the time nor inclination to master the art of manipulation and will wish to refer their patients to a skilled practitioner of this therapy.”

“The physician who makes use of this [manipulation] resource will provide relief for many back pain patients.”

••••

In 2013, Benjamin J Keeney, PhD, was from the Department of Orthopaedics at Dartmouth Medical School. That year, Dr. Keeney and colleagues published a study titled (3):

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury:
Results from a Prospective Study of Workers in Washington State

 This was a prospective population-based cohort study of 1,885 subjects, designed to identify early predictors of lumbar spine surgery within 3 years after occupational back injury from the state of Washington. The authors note, “Reducing unnecessary spine surgeries is important for improving patient safety and outcomes and reducing surgery complications and health care costs.”

Study subjects were assessed using the Roland Morris Disability Questionnaire (RMDQ). The RMDQ has been shown to be predictive of chronic work disability, longer duration of sick leave, chronic pain, and other measures of function.

Study findings include:

“Those with greater injury severity and those whose first provider seen for the injury was a surgeon also had significantly higher odds of surgery, after adjusting for all other variables.”

“42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.”  

“There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.”

“It is possible that these findings indicate that who you see is what you get.”

“In Washington State worker’s compensation, injured workers may choose their medical provider. Even after controlling for injury severity and other measures, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, whereas workers whose first visit was to a chiropractor had significantly lower odds of surgery [by 78%].”

“Approximately 43% of workers who saw a surgeon had surgery within 3 years, in contrast to only 1.5% of those who saw a chiropractor.”

••••

In 2016, William B. Weeks, MD, PhD, was a professor at the Geisel School of Medicine at Dartmouth. That year, Dr. Weeks was the lead author on an article titled (4):

The Association Between Use of Chiropractic Care and Costs of Care
Among Older Medicare Patients with Chronic Low Back Pain and Multiple Comorbidities

Dr. Weeks and colleagues wanted to determine whether use of chiropractic manipulation was associated with lower healthcare costs among multiple-comorbid Medicare beneficiaries with chronic low back pain. Their analysis assessed 72,326 patients. These authors note:

“Medicare reimbursements during the chronic LBP treatment episode were lowest for patients who used [chiropractic manipulation] alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode.”

“Expenditures were greatest for patients receiving medical care alone.”

“Patients who used only [chiropractic manipulation] had the lowest annual growth rates in almost all Medicare expenditure categories.”

“This study found that older multiple-comorbid patients who used only [chiropractic manipulation] during their chronic LBP    episodes had lower overall costs of care, shorter episodes, and lower cost of care per episode day than patients in the other treatment groups.”

“These findings support initial [chiropractic manipulation] use in the treatment of, and possibly broader chiropractic management of, older multiple-comorbid  chronic LBP patients.”

••••

In 2022, Robert James Trager, DC, was a clinical chiropractor and a researcher at the University Hospitals Cleveland Medical Center, Ohio. That year, Dr. Trager and colleagues published a study titled (5):

Association Between Chiropractic Spinal Manipulation and
Lumbar Discectomy in Adults with Lumbar Disc Herniation and Radiculopathy

The authors of this study assessed matched cohorts of 5,785 patients with a mean age of 37 years.

The authors note that it is common for patients with lumbar disc herniations and radiculopathy to receive chiropractic care or undergo surgery to remove herniated disc material, a procedure called discectomy. Prior studies have found that patients who initiate care for low back pain with a chiropractor have significantly reduced odds of having discectomy.

In this study, the relative odds for discectomy were significantly reduced in the chiropractic cohort compared with the cohort receiving other care over 1-year (by 69%) and 2-year follow-up (by 77%). This study shows that patients initially receiving chiropractic care for lumbar disc herniation with radiculopathy have reduced odds of discectomy over 1-year and 2-year follow-up.

Neck Considerations

In 1996, MN Woodward was a researcher at the University Department of Orthopaedic Surgery, Bristol, UK. That year he was the lead author in an article titled (6):

Chiropractic Treatment of Chronic ‘Whiplash’ Injuries

The 28 patients in this study had initially been treated with anti-inflammatory drugs, soft collars, and physiotherapy. These patients had all become chronic and were referred for chiropractic at an average of 15.5 months (range was 3–44 months) after their initial injury.

Following chiropractic care, 93% of the patients had improved. These authors state:

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”

••••

In 2002, Jan Lucas Hoving, PT, PhD, was in the Department of Clinical Epidemiology, Cabrini Hospital, Victoria, Australia. That year he was the lead author of an article titled (7):

Manual Therapy, Physical Therapy, or Continued Care
by a General Practitioner for Patients with Neck Pain:
A Randomized Controlled Trial

In this study, the authors compared the effectiveness of manual therapy, physical therapy, and care by a general practitioner (pharmacology) in the treatment of neck pain. They used a randomized controlled trial design. The study involved 183 patients.

The authors defined “manual therapy” as:

“According to the International Federation of Orthopedic Manipulative Therapies, ‘Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.’”

These authors concluded:

“Manual therapy scored consistently better than the other two interventions on most outcome measures.”

“In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”

“The success rates for manual therapy were statistically significantly higher than those for physical therapy.”

“Manual therapy scored better than physical therapy on all outcome measures…”

“Range of motion improved more markedly for those who received manual therapy or physical therapy than for those who received continued [physician/pharmacology] care.”

“The postulated objective of manual therapy is the restoration of normal joint motion, which was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”

“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care.”

“Manual therapy seems to be a favorable treatment option for patients with neck pain.”

“Primary care physicians should consider manual therapy when treating patients with neck pain.”

••••

In 2013, Cynthia K. Peterson, RN, DC, was a professor of chiropractic medicine and radiology at the Orthopaedic University Hospital Balgrist, Zürich, Switzerland. That year she was the lead author in an article titled (8):

Outcomes from Magnetic Resonance Imaging:
Confirmed Symptomatic Cervical Disk Herniation Patients Treated
with High-Velocity, Low-Amplitude Spinal Manipulation Therapy:
A Prospective Cohort Study With 3-Month Follow-Up

 The purpose of this study was to investigate outcomes of patients with cervical radiculopathy from cervical disk herniation (CDH) who were treated with chiropractic spinal manipulative therapy. The authors used 50 patients with a mean age of 44 years. Treatments were repeated 3 to 5 times per week for the first 2 to 4 weeks and carried on 1 to 3 times per week thereafter until the patient was asymptomatic. They were evaluated at baseline, 2-weeks, 1-month, and 3-months.

All patients in this study had neck pain and moderate to severe arm pain in a dermatomal pattern with sensory, motor, or reflex changes corresponding to the involved nerve root. They also had magnetic resonance imaging-proven CDH at the corresponding spinal segment.

“High-velocity, low-amplitude spinal manipulations were administered by experienced doctors of chiropractic.” These manipulations were delivered to the segmental level of the CDH. The goal of the manipulation was to produce an audible release, which was achieved in most cases. The outcomes were as follows:

• “By 2 weeks after the first treatment, 55.3% of all patients reported that they were significantly improved and none reported being worse.”
• “At 1 month, 68.9% were significantly improved.”
• By 3 months, 85.7% were significantly improved with no patients being worse.
• “There were no adverse events in this cohort of patients.”

The authors noted that the presence of cervical radiculopathy was not a negative predictor of outcomes for these chiropractic patients with CDH. The authors concluded:

“Most patients in this study with MRI-proven symptomatic CDHs who were treated with high-velocity, low-amplitude spinal manipulation reported clinically significant improvement at all time points, particularly at 3 months.”

“Patients with symptomatic MRI-confirmed cervical disk herniations treated with SMT to the level of herniation reported high levels of clinically relevant improvement at 2 weeks, 1 month, and 3 months after the first treatment.”

The authors also noted that chiropractic spinal manipulation for CDH patients with radiculopathy was 2-3 times superior to published studies of patients with CDH with radiculopathy who received 2 cervical nerve root blocks with a corticosteroid and anesthetic.

••••

In 2017, Maggie E Horn, DPT, MPH, PhD, was an assistant professor from the Department of Orthopaedic Surgery at Duke University. That year she was the lead author in a study titled (9):

Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain

The authors note:

“It is imperative to evaluate the difference in health care process and outcomes in patients initially consulting with non-pharmacological providers (ie, chiropractors [DCs] and physical therapists [PTs]) and pharmacological providers (ie, specialists [such as physiatrists and neurologists]) in comparison to PCPs.”

“These specific provider types were included in the analysis because they are the most common providers consulted for neck pain.”

This study looked at a cohort of 1,702 patients seeking care for a new episode of neck pain who consulted a primary care provider (PCP), physical therapist (PT), chiropractor (DC), or specialist:

The health care utilization was assessed at 14 days, 30 days, and 1 year from the initial visit between various providers. The health care utilization assessed included:

• Imaging (MRI, computed tomography, radiography)
• Opioids
• Surgery (spinal arthrodesis, discectomy, laminectomy, or fusion)
• Injections (including nerve blocks)

Based upon these results, the authors make the following important observations:

“Physical therapists and chiropractors primarily treat neck pain with exercise therapy and manual therapy, which has been found to have good effectiveness in treating nonspecific neck pain.” 

“[In contrast], primary care providers’ first line of treatment often includes medication, imaging, specialist referral, or a combination of those factors.”  

“Initial consultation from either a chiropractor or physical therapist decreases the patient’s odds of being prescribed an opioid at 30 days or within any time in the 1-year follow-up period.”

Compared with initial consultation with a primary care provider, the odds of undergoing advanced imaging (MRI or computed tomography) within 1 year “was reduced when the initial provider was a chiropractor and increased when the initial provider was a specialist or a physical therapist.”

“When patients in the sample initially consulted with a chiropractor, the odds of MRI use decreased compared with consulting with a primary care provider.”

“We found that initial consultation with a non-pharmacological provider, such as a chiropractor or physical therapist, is associated with a decrease in the downstream utilization of health care services, and importantly a decrease in opioid use 30 days and 1 year after the initial consultation.”

“Initiating care with a specialist was associated with an increase in the odds of receiving spinal injections and undergoing MRI and radiography and had the highest percentage of patients undergoing surgery.”

“Initially consulting with a specialist for a new episode of neck pain appears to escalate the level of care patients with neck pain receive.” 

“These findings support that initiating care with a non-pharmacological provider for a new episode of neck pain may present an opportunity to decrease opioid exposure (chiropractor and physical therapist) and advanced imaging and injections (chiropractor only).”

“Stronger alignment of physical therapists and chiropractors as front-line providers by health care systems may be needed in light of the widespread [drug] addiction, which has been identified as a public health epidemic.”

Pertaining to chiropractors and the use of spinal x-rays, these authors make these observations:

“Radiographic studies have been a longstanding mainstay of chiropractic practice.”

“Radiography is routinely ordered as part of a [chiropractic] treatment plan and is often performed at the initial visit.”

“It is plausible that the use of radiography may have paradoxically shielded patients from undergoing more advanced imaging such as MRI.”

“When a provider orders imaging, this can alleviate patients’ concern about serious pathology, despite a lack of evidence for clinical utility in routine care of patients with neck pain.”

••••

In 2023, Joshua J. Fenton, MD, MPH, was in the Department of Family Medicine at the University of California, Davis. This year, Dr. Fenton published a study titled (10):

Longitudinal Care Patterns and Utilization Among Patients
with New-Onset Neck Pain by Initial Provider Specialty

This study was a retrospective cohort design involving 777,326 patients, aged 18 to 89 years. Its objective was to compare utilization patterns for patients with new-onset neck pain by initial provider specialty.

Utilization was assessed during a 180-day follow-up period, including subsequent neck pain visits at 30, 90, and 180 days, diagnostic imaging, and therapeutic interventions. Findings from this study include:

“The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%).”

“Compared to patients with PCP or specialist physician initial providers, patients with chiropractor initial providers had substantially lower rates of imaging and invasive therapeutic interventions, including injections and surgery, during a 180-  day follow-up period.”

“As starting with a chiropractor was associated with lower rates of invasive therapeutic interventions and surgery, our study suggests initial care for new-onset neck pain by chiropractors is likely associated with lower longer-term care intensity and costs.”

“Even after extensive adjustment for sociodemographic and clinical characteristics, patients who started with an orthopedic surgeon, … had substantially higher rates of therapeutic injection and major surgery within 180 days of follow-up than patients who started with a chiropractor.”

In this large study, patients who initially saw a chiropractor for their neck pain were 40% less likely to have injections compared to patients who initially saw an orthopedic surgeon. Similarly, patients who initially saw a chiropractor for their neck pain were 97% less likely to have major surgery compared to patients who initially saw an orthopedic surgeon.

The authors note that both the health systems and medical providers,  including specialists, and the patients themselves, would benefit from higher use and referrals to chiropractors for patients suffering from neck pain.

••••

SUMMARY

These studies show the incredible value of chiropractic care to both patients and to our healthcare delivery system. Chiropractic care should be the first option for patients with low back and/or neck pain. Chiropractic care is safe, outcome effective, and cost effective for these musculoskeletal complaints.

REFERENCES

1. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; p. 1335.
2. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
3. Keeney BJ, PhD, Fulton-Kehoe D, PhD, Turner JA, Wickizer TM, Chan KCG, Franklin GM; Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State; Spine; May 15, 2013; Vol. 38; No. 11; pp. 953-964.
4. Weeks, WB, Leininger B, Whedon JM, Lurie JD, MS, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM, The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients with Chronic Low Back Pain and Multiple Comorbidities; Journal of Manipulative and Physiological Therapeutics; February 2016; Vol. 39; No. 2; pp. 63-75.
5. Trager RJ, Daniels CJ, Perez JA, Casselberry RM, Dusek JA: Association Between Chiropractic Spinal Manipulation and Lumbar Discectomy in Adults with Lumbar Disc Herniation and Radiculopathy: Retrospective Cohort Study Using United States’ Data; BMJ Open; December 16, 2022; Vol. 12; No. 12; Article e068262.
6. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic Treatment of Chronic ‘whiplash’ Injuries; Injury; November 1996; Vol. 27; No. 9; pp. 643-645.
7. Hoving JC, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, Mameren H, Devillé WLJM; Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain; A Randomized Controlled Trial; Annals of Internal Medicine; May 21, 2002; 136; No. 10; pp. 713-722.
8. Peterson CK, Schmid C, Leemann S, Anklin B, Humphreys BK; Outcomes from Magnetic Resonance Imaging: Confirmed Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation Therapy: A Prospective Cohort Study With 3-Month Follow-Up; Journal of Manipulative and Physiological Therapeutics; October 2013; Vol. 36; pp. 461-467.
9. Horn ME, George SZ, Fritz JM; Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain; Mayo Clinic Proceedings: Innovations, Quality & Outcomes; October 19, 2017; Vol. 1; No. 3; pp. 226-233.
10. Fenton JJ, Fang SY, Ray M, Kennedy J, Padilla K, MPP, Amundson R, David Elton D, Haldeman S, Lisi AJ, DC, Sico J, Wayne PM, Romano PS; Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty; Spine; October 15, 2023; Vol. 48; No 20; pp. 1409–1418.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”