Integrated Health Care and Chiropractic

This section was compiled by Frank M. Painter, D.C.
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Chiropractic in an Integrative Health Care Model


Patient Satisfaction Cost-Effectiveness Safety of Chiropractic

About Chiropractic Chiropractic Rehab Repetitive Stress

Headache Page Whiplash Section Disc Herniation

Chronic Neck Pain Low Back Pain Stroke & Chiropractic

Iatrogenic Injury Placebo Problems Subluxation Complex

ChiroZine Case Reports Pediatric Section

Conditions That Respond Well Alternative Medicine Approaches to Disease

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Reference Materials

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these articles about chiropractors as first-contact Spinal Health Care Experts.

Pain Management and Chiropractic
A Chiro.Org article collection

Explore this collection of articles that discusses the relationship between tissue injury and various pyschosocial factors that may contribute towards developing chronic pain.

Chronic Neck Pain and Chiropractic
A Chiro.Org article collection

Review this extensive collection of studies detailing how chiropractic and spinal manipulation are effective for the relief of spinal pain.

Neck and Back Pain in Children and Chiropractic
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for spinal pain in children.

Radiculopathy and Chiropractic Page
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for radiculopathy.

Low Back Pain and Chiropractic
A Chiro.Org article collection


The Biopsychosocial Model
A Chiro.Org article collection

The late George Engel believed that to understand and respond adequately to patients’ suffering — and to give them a sense of being understood — clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness. He offered a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century. [1] His new model came to be known as the biopsychosocial model.

Clinical Prediction Rules
A Chiro.Org article collection

Recently, Flynn and colleagues [17] developed a clinical prediction rule for identifying patients with low back pain who are likely to benefit from manipulation. They examined a series of patients with low back pain who received a manipulation intervention. Five factors formed the most parsimonious set of predictors for identifying patients who achieved at least 50% improvement in disability within 1 week with a maximum of 2 manipulation interventions (Table 1) [17]. The positive likelihood ratio among patients who met at least 4 of 5 of the criteria was 24.4 (95% CI, 4.6 to 139.4).

The Prescription Rights and Expanded Practice Debate
A Chiro.Org article collection

There is a growing desire within [a very small percentage of the] chiropractic profession to expand the scope of practice to include limited medication prescription rights for the treatment of spine-related and other musculoskeletal conditions. Such prescribing rights have been successfully incorporated into a number of chiropractic jurisdictions worldwide. If limited to a musculoskeletal scope, medication prescription rights have the potential to change the present role of chiropractors within the healthcare system by paving the way for practitioners to become comprehensive specialists in the conservative management of spine/ musculoskeletal disorders.


Integrated Health Care Articles

Use of Integrative Medicine in the United States Military Health System
Evid Based Complement Alternat Med 2017 (Jun 13);   2017:   9529257

Integrative medicine (IM) is a model of care which uses both conventional and nonconventional therapies in a "whole person" approach to achieve optimum mental, physical, emotional, spiritual, and environmental health, and is increasingly popular among patients and providers seeking to relieve chronic or multifactorial conditions. The US Department of Defense (DoD) shows particular interest in and usage of IM for managing chronic conditions including the signature "polytrauma triad" of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD) among its beneficiaries in the Military Health System (MHS).

Complementary and Integrative Medicine in the Management of Headache
BMJ. 2017 (May 16);   357:   j1805 ~ FULL TEXT

Headaches, including primary headaches such as migraine and tension-type headache, are a common clinical problem. Complementary and integrative medicine (CIM), formerly known as complementary and alternative medicine (CAM), uses evidence informed modalities to assist in the health and healing of patients. CIM commonly includes the use of nutrition, movement practices, manual therapy, traditional Chinese medicine, and mind-body strategies. This review summarizes the literature on the use of CIM for primary headache and is based on five meta-analyses, seven systematic reviews, and 34 randomized controlled trials (RCTs).

Interdisciplinary Practice Models for Older Adults With Back Pain:
A Qualitative Evaluation

Arthritis Res Ther. 2016 (Oct 13);   18 (1):   237

Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups.

Integration of Chiropractic Services in Military and Veteran
Health Care Facilities: A Systematic Review of the Literature

J Evid Based Complementary Altern Med. 2016 (Apr);   21 (2):   115–130

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. A systematic search of Medline, CINAHL, and Index to Chiropractic Literature was performed from inception through April 2015. Thirty articles met inclusion criteria. Studies reporting utilization and policy show that chiropractic services are successfully implemented in various military and veteran health care settings and that integration varies by facility.

The Chiropractic Hospital-Based Interventions Research Outcomes Study:
Consistency of Outcomes Between Doctors of Chiropractic
Treating Patients With Acute Lower Back Pain

J Manipulative Physiol Ther. 2015 (Jun);   38 (5):   311–323 ~ FULL TEXT

The findings of this study show that regardless of the treating DC, most patients with acute LBP without radiculopathy appear to experience consistent levels of improvement in terms of back pain and general physical functioning (PF) after receiving guidelines-based treatment that includes a component of standardized HVLA SMT.

Interprofessional Collaboration in Research, Education,
and Clinical Practice: Working Together for a Better Future

Journal of Chiropractic Education 2015 (Mar);   29 (1):   1–10 ~ FULL TEXT

Interprofessional collaboration occurs when 2 or more professions work together to achieve common goals and is often used as a means for solving a variety of problems and complex issues. The benefits of collaboration allow participants to achieve together more than they can individually, serve larger groups of people, and grow on individual and organizational levels. This editorial provides an overview of interprofessional collaboration in the areas of clinical practice, education, and research; discusses barriers to collaboration; and suggests potential means to overcome them.

A Framework For Chiropractic Training In Clinical Preventive Services
Chiropractic & Manual Therapies 2013 (Aug 20);   21:   28 ~ FULL TEXT

The 2010 Patient Protection and Affordable Care Act provides incentives for both patients and providers to engage in evidence-based clinical preventive services recommended by the United States Preventive Services Task Force (USPSTF). Depending upon the application of the new health care act, Doctors of Chiropractic (DC) may be considered to be covered providers of many of these services. It is therefore essential that DCs’ training prepare them to competently deliver them. The aim of this commentary is to describe a framework for training in clinical preventive services, based largely on the USPSTF recommendations, which could be readily integrated into existing DC educational programs.

The Collateral Benefits Of Having Chiropractic Available
In A Public Central Hospital

Journal of Hospital Administration 2013 (Aug 8);   2 (4):   138–143 ~ FULL TEXT

Following previous reports on the co-operation between a chiropractor and a central hospital, experiences from the past five years are presented. The objective of this paper is to show that improved management of muscular and skeletal problems within a hospital setting depends on the availability of chiropractic health care as a treatment option.

A Health Care System in Transformation:
Making the Case for Chiropractic

Chiropractic & Manual Therapies 2012 (Dec 6);   20 (1):   37 ~ FULL TEXT

There are a number of factors that have conspired to create a crisis in healthcare. In part, the successes of medical science and technologies have been to blame, for they have led to survival where lives would previously have been cut short. An informed public, aware of these technological advances, is demanding access to the best that healthcare has to offer. At the same time the burden of chronic disease in an increasing elderly population has created a marked growth in the need for long term care. Current estimates for expenditure predict a rapid escalation of healthcare costs as a proportion of the GDP of developed nations, yet at the same time a global economic crisis has necessitated dramatic cuts in health budgets. This unsustainable position has led to calls for an urgent transformation in healthcare systems. This commentary explores the present day healthcare crisis and looks at the opportunities for chiropractors as pressure intensifies on politicians and leaders in healthcare to seek innovative solutions to a failing model. Amidst these opportunities, it questions whether the chiropractic profession is ready to accept the challenges that integration into mainstream healthcare will bring and identifies both pathways and potential obstacles to acceptance.

Complementary and Alternative Medicine Use Among Veterans
With Chronic Noncancer Pain

J Rehabil Res Dev. 2011;   48 (9): &nbsnbsp; 1119–1128 ~ FULL TEXT

We describe prior use and willingness to try complementary and alternative medicine (CAM) among 401 veterans experiencing chronic noncancer pain and explore differences between CAM users and nonusers. Participants in a randomized controlled trial of a collaborative intervention for chronic pain from five Department of Veterans Affairs (VA) primary care clinics self-reported prior use and willingness to try chiropractic care, massage therapy, herbal medicines, and acupuncture.

Integrative Care for the Management of Low Back Pain:
Use of a Clinical Care Pathway

BMC Health Serv Res. 2010 (Oct 29);   10:   298 ~ FULL TEXT

Thirteen providers representing 5 healthcare professions collaborated to provide integrative care to study participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into treatment plans.

Are Swiss Chiropractors Different Than Other Chiropractors?
Results of the Job Analysis Survey 2009

J Manipulative Physiol Ther 2010 (Sep);   33 (7):   519–535 ~ FULL TEXT

The response rate was 70%. Similarities between Swiss chiropractors and their international counterparts were found in the most common conditions treated, the common etiologies of these conditions, the most common age groups seen, and the most common treatment methods used. Differences were found in the high proportion of patients referred directly to chiropractors from varying medical specialists in Switzerland, the fact that the most common category of patient to be seen by chiropractors in Switzerland is the acute followed by the subacute patient, the much higher requirement for continuing education hours in Switzerland, and the reduced use of diagnostic imaging compared with practitioners from the United States.

Individualized Chiropractic and Integrative Care for Low Back Pain:
The Design of a Randomized Clinical Trial Using a Mixed-methods Approach

Trials. 2010 (Mar 8);   11:   24 ~ FULL TEXT

This mixed-methods randomized clinical trial assesses clinical effectiveness, cost-effectiveness, and patients' and providers' perceptions of care, in treating non-acute LBP through evidence-based individualized care delivered by monodisciplinary or multidisciplinary care teams.

Contextualizing Integration: A Critical Social
Science Approach to Integrative Health Care

J Manipulative Physiol Ther. 2009 (Nov);   32 (9):   792–797 ~ FULL TEXT

The authors outline a framework and highlight the values of a critical social science perspective in deepening our understanding of recent transformations in health care practice and issues surrounding biomedicine and complementary/alternative medicine (including chiropractic, naturopathy, massage, acupuncture/oriental medicine, etc) and traditional medicine. A critical social science perspective pays special attention to complex power relations, inclusionary/exclusionary strategies, and interprofessional dynamics in medicine.

Health Care Transitions: A Review of Integrated,
Integrative, and Integration Concepts

J Manipulative Physiol Ther. 2009 (Nov);   32 (9):   703–713 ~ FULL TEXT

In this article, several views of the terms integration, integrated, and integrative are considered with the hopes that this brief review will help to raise awareness, clarify various uses of these terms, and add to the continuing discussion of integration and how we might improve health care. Models of integrative care, views of integration, and samples of different interpretations and definitions are offered.

An Analysis of the Integration of Chiropractic Services Within the
United States Military and Veterans' Health Care Systems

J Manipulative Physiol Ther. 2009 (Nov);   32 (9):   749–757 ~ FULL TEXT

We identified 9 areas wherein potential opportunities and threats to integration existed, including legislative history, programmatic growth, leadership structure, employment status of providers, clinical work duties, patient access, patient demographics, academic affiliations, and research.   These findings provide a higher level of understanding regarding the current state and future direction of chiropractic service integration within these integrated health care systems.

Integrated Musculoskeletal Rehabilitation Care at a Comprehensive
Combat and Complex Casualty Care Program

J Manipulative Physiol Ther. 2009 (Nov);   32 (9):   781–791 ~ FULL TEXT

After construction of the facility in 2007, the program has provided services for approximately 2 years. Eighteen different health care providers from 10 different specialties provide integrated musculoskeletal services, which include primary care, physical therapy, occupational therapy, vestibular therapy, gait analysis, prosthetics, recreational therapy, and chiropractic care. At the time of this writing (early 2009), the program had provided musculoskeletal rehabilitation care to approximately 500 patients, 58 with amputations, from the operational theater, Veterans Affairs, other military treatment facilities, and local trauma centers.

Hospital-Based Chiropractic Integration Within a Large Private Hospital
System in Minnesota: A 10-Year Example

J Manipulative Physiol Ther. 2009 (Nov);   32 (9):   740–748

This article describes the process of integrating chiropractic into one of the largest private hospital systems in Minnesota from a business and professional perspective and the results achieved once chiropractic was integrated into the system. This study identified key factors that facilitated integration of services and demonstrates that chiropractic care can be successfully integrated within a hospital system.

A Nonsurgical Approach to the Management of Patients With
Lumbar Radiculopathy Secondary to Herniated Disk:
A Prospective Observational Cohort Study With Follow-Up

J Manipulative Physiol Ther 2009 (Nov);   32 (9):   723–733 ~ FULL TEXT

A randomized trial by researchers at an outpatient rehabilitation department in Italy involving 210 patients with chronic, nonspecific low back pain compared the effects of spinal manipulation, physiotherapy and back school. The participants were 210 patients (140 women and 70 men) with chronic, non-specific low back pain, average age 59. Back school and individual physiotherapy were scheduled as 15 1–hour-sessions for 3 weeks. Back school included group exercise and education/ergonomics. Individual physiotherapy included exercise, passive mobilization and soft-tissue treatment. Spinal manipulation included 4–6 20–minute sessions once-a-week. Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

Chiropractic Practice in Military and Veterans
Health Care: The State of the Literature

J Can Chiropr Assoc. 2009 (Aug);   53 (3):   194–204 ~ FULL TEXT

Chiropractic services seem to be included successfully within military and veteran health care facilities. However, there is a great need for additional written evaluation of the processes, policies, practices, and effectiveness of chiropractic services in these environments.

A New Conceptual Model Of Neck Pain: Linking Onset, Course, And Care:
The Bone and Joint Decade 2000-2010 Task Force
on Neck Pain and Its Associated Disorders

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S17–28 ~ FULL TEXT

This article describes the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) conceptual model for the onset, course, and care of neck pain. We start with the scope and rationale for proposing a new conceptual model, followed by its purposes and premises. After describing the model's components and associated case definitions, we conclude with a discussion on implications of the model.

Clinical and Cost Outcomes of an Integrative Medicine IPA
J Manipulative Physiol Ther 2004 (Jun) ;   27 (5):   336–347 ~ FULL TEXT

Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame.

Economic Case for the Integration of Chiropractic Services
into the Health Care System

J Manipulative Physiol Ther 2000 (Feb);   23 (2):   118–122 ~ FULL TEXT

For much of its history, chiropractic care has been both an alternative therapeutic paradigm and separate from or marginal to the mainstream health care system. Over the past decade, the situation has changed somewhat in that chiropractic care is gradually being integrated within a variety of health care delivery organizations. According to Triano et al,1 by the application of evidence-based health care and good business, there is a surge in cooperation and integration among chiropractors, allopathic physicians, allied health care providers, ancillary therapists, and respective support staff. There is, however, no quantification of the level of integration. Integration may also be more true of the United States than elsewhere. The overall position of chiropractic care as alternative and separate still predominates. This situation does not serve the interests of the chiropractic profession nor the public well. There is a persuasive economic case for a radical shift in the role of chiropractic care to one that may succinctly be described as alternative and mainstream.   The chiropractic profession must preserve its identity and its unique therapeutic paradigm and continue to be seen as an alternative to other health care professions, especially medical doctors. However, it should also become mainstream and thus widely available and accessible to the public by being integrated into the wide variety of health care delivery organizations that collectively constitute the health care system.


Chiropractic in an Integrative Health Care Model

Principles of Integrative Medicine

Creating an integrative medicine model for patient care is about more than randomly choosing between methods of the traditional healthcare system and the alternative medicine sector. Integrative healthcare, to effectively treat chronic pain, combines any and all safe and effective treatment modalities, without regard for whether the modality originated in the allopathic, pharmaceutical or CAM arena.

Chiropractic and Spinal Pain Management
A Chiro.Org article collection

Enjoy these articles about chiropractic integration into HMOs, IPAs and the Veterans program..

An Integrated Approach to Chronic Pain
Dynamic Chiropractic ~ May 2017 ~ FULL TEXT

Findings from a unique Medicaid pilot project in Rhode Island involving high-use Medicaid recipients from two health plans were recently presented to the state's Department of Health, [1] demonstrating stellar outcomes with regard to medication use, ER visits, health care costs and patient satisfaction.   Since 2012, Rhode Island Medicaid "Community of Care" enrollees suffering from chronic pain have participated in an integrated chronic pain program administered by Advanced Medicine Integration. Longtime readers will recall that for nearly two decades, AMI has been coordinating chiropractic and integrated care services in various states to help address the chronic pain epidemic in a community-based, integrated fashion. [2-3]

Integrative Health Care for a Medicaid Population:
Interview with Alan Post, D.C.

Topics in Integrative Health Care 2012;   3 (4) ~ FULL TEXT

In the United States, Medicaid is the government-sponsored health insurance program for people with the lowest incomes and many who are disabled. Medicaid is paid for by a combination of federal and state government funds, with the federal share covering the majority of costs. In the state of Rhode Island, Medicaid initiated in 2012 a pilot program under which management of patients with chronic pain would include the option of chiropractic, acupuncture and massage therapy services. In this interview with Rhode Island chiropractor Alan Post, DC, he describes the specifics of the program and emphasizes its cost-saving potential.   Alan R. Post, DC, is past president of the Chiropractic Society of Rhode Island and the New England Chiropractic Council. He holds a Bachelor of Science in Human Biology and graduated with honors from Logan College of Chiropractic in 1982. At various points in his career, he has served as a state-appointed Medical Examiner for the Rhode Island Workers’ Compensation System, as a member of the Rhode Island Blue Cross Specialty Advisory Board for Chiropractic, the Specialty Advisory Board for the Physician One Health Plan. He currently serves as a member of the Advisory Board at the University of Bridgeport Chiropractic College.

Individualized Chiropractic and Integrative Care for Low Back Pain:
Integrative Care for the Management of Low Back Pain:
Use of a Clinical Care Pathway

BMC Health Serv Res. 2010 (Oct 29);   10:   298 ~ FULL TEXT

Thirteen providers representing 5 healthcare professions collaborated to provide integrative care to study participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into treatment plans.

AMI Model Working in Florida: Functional Improvements,
Reduced Utilization Costs by Medicaid Patients

Dynamic Chiropractic ~ April 22, 2008 ~ FULL TEXT

Background:   Alternative Medicine Integration (AMI) originally achieved recognition within the chiropractic community for its unique HMO model that utilized doctors of chiropractic as primary-care physicians (PCPs) and the portal of entry into an integrated health care delivery system, inclusive of hospitals, MDs and MD specialists and outpatient facilities.   Contracted with Blue Cross Blue Shield's HMO-Illinois, AMI's integrated IPA demonstrated excellent clinical and cost outcomes.   These outcomes were published in the June 2007 issue of JMPT and reviewed in the June 4, 2007 issue of DC. [1] In July 2007, AMI received the national endorsement of the Congress of Chiropractic State Associations (COCSA) for its outcomes-based model of chiropractic medical management.

Chiropractors as Primary Care Providers
Dynamic Chiropractic ~ June 4, 2007 ~ FULL TEXT

The latest issue of the Journal of Manipulative and Physiological Therapeutics features an update to Sarnat and Winterstein's 2004 research paper that assessed chiropractors' effectiveness as primary care providers (PCPs).   As with the 2004 report, the latest research concludes that a managed care network with chiropractic gatekeepers saves substantial costs and results in decreased utilization as compared to PCPs using conventional medicine alone.

Clinical Utilization and Cost Outcomes from an Integrative Medicine
Independent Physician Association: An Additional 3-year Update

J Manipulative Physiol Ther 2007 (May);   30 (4):   263–269 ~ FULL TEXT

The initial report (JMPT 2004 (Jun) ; 27 (5): 336–347) analyzed clinical and cost utilization data from the years 1999 to 2002 for an integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were exclusively doctors of chiropractic.

This report updates the subsequent utilization data from the IPA for the years 2003 to 2005 and includes first-time comparisons in data points among PCPs of different licensures who were oriented toward complementary and alternative medicine (CAM).   The authors found that:

“During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.”

The savings?   Clinical and cost utilization based on 70,274 member-months over a 7-year period
demonstrated decreases of:

60.2% in-hospital admissions
59.0% less hospital days
62.0% less outpatient surgeries and procedures and
85% less pharmaceutical costs

when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.

Clinical and Cost Outcomes of an Integrative Medicine IPA
J Manipulative Physiol Ther 2004 (Jun) ;   27 (5):   336–347 ~ FULL TEXT

In 1999, a large Chicago HMO began to utilize doctors of chiropractic (DCs) in a primary care provider role. The DCs focused on assessment and evaluation of risk factors and practiced with a non-pharmaceutical/non-surgical approach. Insurance claims and patient surveys were analyzed to compare clinical outcomes, costs and member satisfaction with a normative control group.

During the 4-year study, this integrative medical approach, emphasizing a variety of complimentary and alternative medical (CAM) therapies, resulted in lower patient costs and improved clinical outcomes for patients. The patients who went to DCs as their primary care providers had

43 percent decreases in hospital admissions,
52 percent reductions in pharmaceutical costs and
43 percent fewer outpatient surgeries and procedures

If you like these results, you will absolutely LOVE the 7-Year Follow-Up!

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