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The First Domino: Chiropractic Before Spinal Surgery for Chronic Low Back Pain

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The First Domino:
Chiropractic Before Spinal Surgery for Chronic Low Back Pain

The Chiro.Org Blog

SOURCE:   Dynamic Chiropractic

By Peter W. Crownfield

University of Pittsburgh Medical Center Health Plan mandates conservative care before even considering surgery for chronic Low Back Pain cases.

The University of Pittsburgh Medical Center (UPMC) Health Plan, a health maintenance organization affiliated with the university’s School of Medicine, has adopted landmark guidelines for the management of chronic low back pain.

As of Jan. 1, 2012, candidates for spine surgery must receive “prior authorization to determine medical necessity,” which includes verification that the patient has “tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication.

Surgery candidates also must be graduates of the plan’s LBP health coaching program. The program features a Web-based decision-making tool designed to help plan members “understand the pros and cons of surgery and high-tech radiology.” It is the first reported implementation of such a policy by a health care plan.

Putting a Clamp on the Soaring Rates of Spine Surgery

According to the December 2011 issue of the UPMC Health Plan Physician Partner Update, which informed participating providers of the new guidelines and the rationale for their implementation, “We feel strongly that this clinical initiative will improve the quality of care for members who are considering low back surgery, and that it will facilitate their involvement in the decision-making process.”

The update also noted, “Surgical procedures for low back surgery performed without prior authorization will not be reimbursed at either the specialist or the hospital level.”

Although I re-titled todays posting as “The First Domino“, the first domino actually fell in November 2004, with the publication of the:

European Guidelines for the Management of Chronic Non-specific Low Back Pain“.

Our June 25th, 2010 review of these Guidelines is available for your review.

The salient points include the fact that almost ALL of what’s considered “standard conservative medical treatment” is listed as invasive treatments, that should NOT be recommended for non-specific Chronic Low Back Pain (CLBP).   (see list below)

Aside from recommending spinal manipulation as a well-supported treatment, the invasive treatments they rail against include:

  • Bed rest
  • Local facet nerve blocks
  • Epidural corticosteroids
  • Intradiscal injections
  • Trigger point injections
  • Intra-articular (facet) steroid injections
  • Acupuncture
  • Prolotherapy
  • Botulinum toxin
  • Intradiscal radiofrequency lesioning
  • Intradiscal electrothermal therapy
  • Radiofrequency facet denervation
  • Radiofrequency lesioning of the dorsal root ganglion, and
  • Spinal cord stimulation

A Conservative Strategy for Managing Chronic LBP

  • PCP discussion related to self-care consisting of rest, ice, compression and elevation (RICE)

  • Screening for psychosocial factors or “yellow flags” and incorporate behavioral interventions as appropriate with other treatment interventions

  • Education on self-management techniques – functional ability assessment and education on return to work / usual activity and function

  • Enrollment and graduation from UPMC Health Plan Health Coach’s Low Back Pain Program (mandatory) which may also include participation in other programs such as weight loss, physical activity, tobacco cessation, depression and/or stress

  • Early referral to chiropractor or physical therapist, but before advanced imaging, for manipulation/ mobilization; stabilization exercises; directional preference strategies – member and/or provider movements that abolish or cause centralization of pain (McKenzie self-treatment repeated movements that centralize pain)

  • Detailed documentation of extent and response to conservative treatment including chiropractor/physical therapy documentation

    SOURCE: UPMC Health Plan Policy and Procedure Manual, October 2011:
    Surgical Management of Low Back Pain
    Review the complete Policy.

Commenting on the UPMC Health Plan guidelines, Gerard Clum, DC, former president of the World Federation of Chiropractic and Life Chiropractic College West, and current executive committee member of the Foundation for Chiropractic Progress, stated:

The UPMC should be congratulated for its leadership is establishing policies to assure that the least invasive and most likely to be successful care strategies, including chiropractic care, are applied for a meaningful period of time, before surgical considerations are made. This decision is both an important recognition of the value of chiropractic care in the chronic low back pain environment, as well as a recognition of the clinical and economic downsides to spinal surgery in this situation.”

Chiropractic Services:
What the UPMC Health Plan Covers

“It is the policy of UPMC Health Plan to recognize chiropractic services and adjunctive procedures as appropriate and consistent with good medical practice and will provide coverage when the services are medically necessary and covered by the member’s benefit plan for the specific indications detailed in this policy. Coverage is limited to medically necessary services provided by a licensed doctor of chiropractic, within the scope of his/her license.”

“Covered chiropractic services include evaluation and management, manipulation, spinal X-rays, therapeutic exercise, and adjunctive procedures that are appropriate and medically necessary for neuromusculoskeletal conditions.”

About the Author:

I was introduced to Chiro.Org in early 1996, where my friend Joe Garolis helped me learn HTML, the "mark-up language" for websites. We have been fortunate that journals like JMPT have given us permission to reproduce some early important articles in Full-Text format. Maintaining the Org website has been, and remains, my favorite hobby.


  1. Russell Berg D.C. May 20, 2012 at 7:45 pm

    It could be that because of our economic outlook for health care in this country, chiropractic may actually get the attention it has deserved for years. We have been told that we needed more research on chiropractic and now that we have it maybe we can move forward. I still think that the medical model will be difficult to fight against, but this is great news.

    • Frank M. Painter, D.C. May 20, 2012 at 8:35 pm

      Hi Russell

      Actually, it’s the dollars and sense that will turn the tides, no matter how powerful the medical lobbies are.

      What can really screw things up is Doctors agreeing to accept Medicare rates, like so many have done in the past, just to get on their provider lists. If everyone wised up, and no one signed, then they’s HAVE to offer a more reasonable rate (like the BCBS rate card).

      I rejected every contract that asked me to cut my fees by 40%. Why bother working just to cover your overhead?

  2. karl May 23, 2012 at 10:59 pm

    I basically agree with both of you guys, but I will add a few opinions. First of all, chiropractic but more specifically osseous manipulation should be considered for most/many NMS conditions. Having said that physical therapist are aware of this and are selling themselves to be first in line to treat these patients/conditions. On the economic front chiropractors haven’t received a raise in years, but overhead continues to goes up. HMO’s have a lot to do with it but even more disturbing is the chiropractors that had group practices in the eighties and early ninties that struck deals with insurance companies that were favorable for them and the insurance companies at the expense of the chiropractic community. This paperwork game and this expectation to have positive outcomes within 1-2 visits/treatments is often unrealistic.

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