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Initial Provider/First Contact
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This section was compiled by Frank M. Painter, D.C.
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Conditions That Respond Alternative Medicine Approaches to Disease


Recent Studies

Cost of Chiropractic Versus Medical Management of
Adults with Spine-related Musculoskeletal Pain:
A Systematic Review

Chiropractic & Manual Therapies 2024 (Mar 6); 32: 8 ~ FULL TEXT

Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. A primary limitation was related to the heterogeneity and sample sizes of the populations and retrospective data sets. While observational studies cannot prove causation, the recurrent theme of the data seems to support the utilization of chiropractors as the initial provider for an episode of spine-related musculoskeletal pain. Future studies using randomized designs will be helpful in clarifying and validating this trend.

Chiropractic Spinal Manipulation and Likelihood of Tramadol
Prescription in Adults with Radicular Low Back Pain:
A Retrospective Cohort Study Using US Data

BMJ Open 2024 (May 1); 14 (5): e078105 ~ FULL TEXT

After propensity matching, there were 1,171 patients per cohort (mean age 35 years). Tramadol prescription was significantly lower in the chiropractic spinal manipulation (CSM) cohort compared with the usual medical care cohort, with an RR (95% CI) of 0.32 (0.18 to 0.57; p<0.0001). A cumulative incidence graph demonstrated that the reduced incidence of tramadol prescription in the CSM cohort relative to the usual medical care cohort was maintained throughout 1-year follow-up. Utilisation of NSAIDs, physical therapy evaluation and lumbar imaging was similar between cohorts.

Patient and Provider Characteristics Associated with
Therapeutic Intervention Selection in a Chiropractic
Clinical Encounter: A Cross-sectional Analysis
of the COAST and O-COAST Study Data

Chiropractic & Manual Therapies 2023 (Sep 21); 31 : 39 ~ FULL TEXT

In a sample of more than 10,000 diagnostic encounters with chiropractors in Victoria, Australia and Ontario, Canada, joint manipulation was the most common therapeutic intervention for spine-related problems, whereas soft tissue therapies were more common for extremity problems. Several patient and provider characteristics were associated with therapeutic intervention selection. These data may be used to support further research on appropriate selection of therapeutic interventions for common musculoskeletal complaints.

Exploring Usual Care for Patients with Low Back Pain
in Primary Care: A Cross-sectional Study of
General Practitioners, Physiotherapists
and Chiropractors

BMJ Open 2023 (Aug 30); 13 (8): e071602 ~ FULL TEXT

The study points to a substantial variation in elements of care provided by GPs, PTs and DCs to patients with LBP. We provide some evidence that indicates differences in practice patterns between clinicians within and across professions that challenge the stereotypical images of clinicians and usual care as a uniform concept within groups of clinicians. Longitudinal data and qualitative enquiry are needed to assess if or how care is tailored to individual patients.

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

Spine (Phila Pa 1976) 2023 (Aug 1) [EPUB] ~ FULL TEXT

The cohort included 770,326 patients with new-onset neck pain visits. The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%). Initial provider specialty was strongly associated with the receipt of subsequent neck pain visits with the same provider specialty. Rates and types of diagnostic imaging and therapeutic interventions during follow-up also varied widely by initial provider specialty. While uncommon after initial visits with chiropractors (≤2%), CT or MRI scans occurred in over 30% of patients with initial visits with emergency physicians, orthopedists, or neurologists. Similarly, 6.8% and 3.4% of patients initially seen by orthopedists received therapeutic injection and major surgery, respectively, as compared to 0.4% and 0.1% of patients initially seen by a chiropractor.   Within a large, national cohort, chiropractors were the initial provider for a plurality of patients with new-onset neck pain. Compared to patients initially seen by physician providers, patients with chiropractor initial providers received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions during follow-up.

Association Between Chiropractic Spinal Manipulation and
Gabapentin Prescription in Adults With Radicular Low
Back Pain: Retrospective Cohort Study Using US Data

BMJ Open 2023 (Jul 21); 13 (7): e073258 ~ FULL TEXT

Our findings suggest that US adults receiving CSMT for newly diagnosed radicular low back pain (rLBP) have significantly reduced odds of receiving a gabapentin prescription over 1–year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.

First Provider Seen for an Acute Episode of Low Back
Pain Influences Subsequent Health Care Utilization

Phys Ther 2023 (Jun 28); pzad067 ~ FULL TEXT

Overall, there appears to be an association between the first choice of provider and future health care utilization. Chiropractic care and physical therapy provide nonpharmacologic and nonsurgical, guideline-based interventions. Their participation appears related to a decrease in immediate and long-term utilization of health care resources. This study expands the existing body of literature and provides a compelling case for the influence of the first provider on an acute episode of LBP.   The first provider seen for an acute episode of LBP influences immediate treatment decisions, the trajectory of a specific patient episode, and future health care choices in the management of LBP.

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 2022 (Dec 16); 12 (12): e068262 ~ FULL TEXT

These findings suggest that patients receiving CSMT for newly diagnosed LDH and/or LSR without serious pathology, spinal deformity or absolute indications for surgery have significantly reduced odds of discectomy through 2-year follow-up after index diagnosis compared with those receiving other care. While socioeconomic variables were unavailable in the dataset, current data suggests these unmeasured variables would not completely explain our findings. However, given the possibility of residual confounding, the efficacy of CSMT for LDH/LSR should be explored further using a randomised controlled trial.

Influence of Initial Health Care Provider on Subsequent
Health Care Utilization for Patients With a New
Onset of Low Back Pain: A Scoping Review

Physical Therapy 2022 (Nov 1); 102 (12): pzac150 ~ FULL TEXT

Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with low back pain. High-quality randomized controlled trials are needed to confirm our findings.

Providing Information at the Initial Consultation
to Patients with Low Back Pain Across General
Practice, Chiropractic and Physiotherapy -
A Cross-sectorial Study of
Danish Primary Care

Scand J Prim Health Care 2022 (Oct 31); 1–9

Across the Danish primary care settings that manage patients with LBP, the guideline-recommended emphasis on patient information is not provided in more than a quarter of first-time consultations. Large variation in providing information exists across the settings, and the proportions provided with information increase for the sub-populations having elevated distress and back-related leg pain below the knee.

Association of Chiropractic Care With Receiving
an Opioid Prescription for Noncancer Spinal Pain
Within a Canadian Community Health Center:
A Mixed Methods Analysis

J Manipulative Physiol Ther 2022 (Aug 23); S0161-4754(22)00086-0 ~ FULL TEXT

Our analysis found that patients with spine pain who received chiropractic care were less likely to receive opioids compared to patients who did not receive chiropractic care. This relationship was most pronounced among patients with early access to chiropractic services. Four themes emerged in our qualitative interviews, including patient self-efficacy, access to chiropractic services, stigma regarding use of opioids, and impact of treatment, which provide a richer understanding of this association.

A Retrospective Analysis of Pain Changes and
Opioid Use Patterns Temporally Associated
with a Course of Chiropractic Care at a
Publicly Funded Inner-city Facility

J Can Chiropr Assoc 2022 (Aug); 66 (2): 107–117 ~ FULL TEXT

The results of the present study found a statistically and clinically significant pain reduction concomitant with publicly funded chiropractic management in a low-income population who utilized opioids. Additionally, a reduction in opioid use, compared to baseline, was found following a course chiropractic management at a multidisciplinary healthcare facility where the majority of patient referrals came from primary care physicians, and resulted in an endpoint of musculoskeletal care for the majority of individuals treated by the onsite chiropractors.

Health Care Resource Utilization in Management
of Opioid-Naive Patients With Newly
Diagnosed Neck Pain

JAMA Netw Open 2022 (Jul 1); 5 (7): e2222062 ~ FULL TEXT

Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain. In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.

Associations Between Early Chiropractic Care and
Physical Therapy on Subsequent Opioid Use Among
Persons With Low Back Pain in Arkansas

J Chiropractic Medicine 2022 (Jun); 21 (2): 67–76 ~ FULL TEXT

In this study we found that receipt of chiropractic care, though not PT, may have disrupted the need for opioids and, in particular, long-term opioid use (LTOU) in newly diagnosed LBP. These authors are to be praised for publishing this paper. When you look at their pedigrees, it's reasonable to imagine that they may have been looking to see that physical therapy was associated with reduced opioid use. Numerous studies have shown that chiropractic already has a well-established track record for low- to no-opioid use, so they would be the perfect comparison group for a study like this. We all know that third parties are looking for safe and cost-effective alternatives to “usual care”. In the past, a study favorable to chiropractic care, particularly one that used physical therapy as a comparison group, would never have been published, because of the long-standing medical bias against chiropractic care. So, let's tip our hats to this group of researchers for their hard work and honesty!

Where to Start? A Two Stage Residual Inclusion
Approach to Estimating Influence of the Initial
Provider on Health Care Utilization and Costs
for Low Back Pain in the US

BMC Health Serv Res 2022 (May 23); 22 (1): 694 ~ FULL TEXT

Total cost of care was lowest when starting with a chiropractor ($5,093) or primary care physician ($5,660), and highest when starting with an orthopedist ($9,434) or acupuncturist ($9,205). This study found that health care utilization and cost varied by the health care provider type seen on the initial visit for individuals with LBP. The first health care provider seen may also affect the use of evidence-based clinical practice guidelines. Finally, early and long-term opioid use for individuals with LBP varied significantly based on the initial health care provider. While a prospective randomized control trial remains the gold standard for controlling for selection bias, this study provides a large-scale, national view of the complex and real-world relationship between the first provider and subsequent health care utilization and costs. While continued research is needed to fully understand the reasons for cost and utilization differences among the providers, this study suggests that US policymakers should consider current insurance, regulatory and government policy to encourage individuals to seek care from providers that follow clinical practice guidelines.

Provider-patient Communication: An Illustrative
Case Report of How Provider Language Can
Influence Patient Prognosis

J Can Chiropr Assoc 2022 (Apr); 66 (1): 85–91 ~ FULL TEXT

Patient-provider communication can lead to unhelpful ideas and beliefs about a patient's condition, negatively impacting their clinical outcome. A 34-year-old male Veteran presented for an evaluation of high impact chronic low back pain. Previous interactions with various healthcare providers resulted in the Veteran viewing his condition as ominous and in need of intervention, however clinical findings did not support these beliefs. Our Veteran underwent six visits in the chiropractic clinic with treatment consisting of pain education, utilization of cognitive behavioral principles, active home care exercises and spinal manipulation, resulting in improvements in functional and objective outcome measures. This case report highlights the impact of misalignment between an early contact healthcare provider and patient misunderstanding of their condition on long term outcomes. It serves as an example of how physicians utilizing pathoanatomic explanations to describe a patient's chronic low back pain diagnosis can alter the patient's beliefs about their condition.

Characteristics, Expectations, Experiences of Care,
and Satisfaction of Patients Receiving Chiropractic
Care in a French University ospital in Toulouse
(France) Over One Year: A Case Study

BMC Musculoskelet Disord 2022 (Mar 9); 23 (1): 229 ~ FULL TEXT

Most participants presented with chronic neck and low back pain and depressive symptoms. We identified facilitators and barriers for patient expectation and satisfaction with chiropractic care in a hospital setting. These will need to be addressed in order to improve our partnership and the satisfaction of our patients. Future study should explore the practitioner’s experience and perspective. This study provides the first data regarding the collaboration between chiropractors and physicians in France. These findings will inform the improvement of our partnership, student’s training and the development of future hospital-based collaborations integrating chiropractic care in a multidisciplinary team.

Three Patterns of Spinal Manipulative Therapy
for Back Pain and Their Association With
Imaging Studies, Injection Procedures,
and Surgery: A Cohort Study
of Insurance Claims

J Manipulative Physiol Ther 2021 (Nov); 44 (9): 683–689

We performed a retrospective cohort study of insurance claims data from a single Fortune 500 company. The 3 care patterns we analyzed were initial spinal manipulative therapy, delayed spinal manipulative therapy, and no spinal manipulative therapy. The 3 procedures analyzed were imaging studies, injection procedures, and back surgery. We considered "escalated care" to be any claims with diagnostic imaging, injection procedures, or back surgery. Modified-Poisson regression modeling was used to determine relative risk of escalated care. For claims associated with initial episodes of back pain, initial spinal manipulative therapy was associated with an approximately 30% decrease in the risk of imaging studies, injection procedures, or back surgery compared with no spinal manipulative therapy. The risk of imaging studies, injection procedures, or back surgery in episodes in the delayed spinal manipulative therapy group was higher than those without spinal manipulative therapy.

Characteristics of Older Adults with Back Pain
Associated with Choice of First Primary Care
Provider: A Cross-sectional Analysis from
the BACE-N Cohort Study

BMJ Open 2021 (Sep 17); 11 (9): e053229 ~ FULL TEXT

We found that nearly all older adults with back pain seeking primary care had experienced back pain previously, and recurring episodes were common. In general, patients with more severe back-related disability and other clinical symptoms and signs were more likely to visit a GP or a PT than a chiropractor. Our results suggest that important patient characteristics are associated with older adult’s choice of primary care providers due to back pain, which may affect the clinical course of back pain for these patients.

Attitudes Towards Chiropractic: A Repeated
Cross-sectional Survey of Canadian Family Physicians

BMC Family Practice 2021 (Sep 15); 22 (1): 188 ~ FULL TEXT

Although generally positive, Canadian family physicians’ attitudes towards chiropractic range from very positive to extremely negative, and most physicians acknowledge that practice diversity within the chiropractic profession presents a barrier to interprofessional collaboration. Efforts to improve relations could include providing evidence-based information on chiropractic during medical training, and increased opportunities for family physicians and chiropractors to interact.

Initial Choice of Spinal Manipulation Reduces
Escalation of Care for Chronic Low Back Pain
Among Older Medicare Beneficiaries

Spine (Phila Pa 1976) 2021 (May 11) [EPUB] ~ FULL TEXT

SMT was associated with lower rates of escalation of care as compared to Opioid Analgesic Therapy (OAT).   Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy. Level of Evidence: 3.

Initial Management of Acute and Chronic
Low Back Pain: Responses from Brief
Interviews of Primary Care Providers

J Altern Complement Med 2021 (Mar); 27 (S1): S106–S114~ FULL TEXT

While most PCPs indicated they were familiar with the ACP guideline, nonpharmacologic treatments were not recommended for patients with acute symptoms. Further dissemination and implementation of the ACP guideline are needed.

Association of Initial Provider Type on Opioid Fills
for Individuals With Neck Pain

Archives of Phys Med and Rehabilitation 2020 (Aug); 101 (8): 1407–1413 ~ FULL TEXT

Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%–91% less likely to fill an opioid prescription in the first 30 days, and between 41%–87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47–3.69; P<.001).

Experiences with Chiropractic Care for Patients
with Low Back or Neck Pain

J Patient Exp 2020 (Jun); 7 (3): 357–364 ~ FULL TEXT

We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points).   The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.

Primary Care for Low Back Pain:
We Don't Know the Half of It

Pain. 2020 (Apr); 161 (4): 663–665 ~ FULL TEXT

In a new systematic review, Kamper et al. [What is Usual Care for Low Back Pain?] (See it directly below this article) tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, [17] and there is good evidence for what constitutes best first-contact treatment. [6] The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit). [2, 3, 16]
Refer to our extensive Low Back Pain collection, titled: What is Usual Care?

What is Usual Care for Low Back Pain? A Systematic
Review of Health Care Provided to Patients with
Low Back Pain in Family Practice and
Emergency Departments

Pain. 2020 (Apr); 161 (4): 694–702 ~ FULL TEXT

International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis.   Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs.
Refer to our extensive Low Back Pain collection, titled: What is Usual Care?

Treatment of Patients with Low Back Pain:
A Comparison of Physical Therapy
and Chiropractic Manipulation

Healthcare (Basel) 2020 (Feb 24); 8 (1): 44 ~ FULL TEXT

This study analyzed these two strategies and showed that in the short term, chiropractic care is a more cost-effective alternative compared to PT for the treatment of acute low back pain. Chiropractic resulted in a lower cost ($48.56) and higher DALY (0.0043) than the PT over a one-month treatment period and five months follow-up. However, the marginal cost-effectiveness of chiropractic over PT suggests that both treatments were quite similar. Such findings are in line with the earlier studies, which found that the effectiveness and total costs of chiropractic and PT as primary treatments were similar to each other right after treatment and after 6 months follow-up. [3, 22, 32]

The Features and Burden of Headaches Within
a Chiropractic Clinical Population:
A Cross-sectional Analysis

Complementary Therapies in Medicine 2020 (Jan); 48: 102276 ~ FULL TEXT

One in four participants (n = 57; 25.4%) experienced chronic headaches and 42.0% (n = 88) experienced severe headache pain. In terms of headache features, 20.5% (n = 46) and 16.5% (n = 37) of participants had discrete features of migraine and tension-type headache, respectively, while 33.0% (n = 74) had features of more than one headache type. 'Severe' levels of headache impact were most often reported in those with features of mixed headache (n = 47; 65.3%) and migraine (n = 29; 61.7%). Patients who were satisfied or very satisfied with headache management by a chiropractor were those who were seeking help with headache-related stress or to be more in control of their headaches. Many with headache who consult chiropractors have features of recurrent headaches and experience increased levels of headache disability. These findings may be important to other headache-related healthcare providers and policymakers in their endeavours to provide coordinated, safe and effective care for those with headaches.

Observational Retrospective Study of the
Association of Initial Healthcare Provider
for New-onset Low Back Pain with Early
and Long-term Opioid Use

BMJ Open. 2019 (Sep 20); 9 (9): e028633 ~ FULL TEXT

Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Implementation Interventions for Musculoskeletal
Programs of Care in the Active Military and
Barriers, Facilitators, and Outcomes of
Implementation: A Scoping Review

Implement Sci. 2019 (Aug 16); 14 (1): 82 ~ FULL TEXT

Musculoskeletal disorders are a leading cause of disability in the military and effective treatment strategies are required to improve return to duty and maintain operational readiness. However, implementing programs of care is challenging given the complexity of the military healthcare system. We synthesized the available scientific literature regarding implementation interventions for musculoskeletal programs of care in the active military, and the barriers, facilitators, and outcomes of implementation. Further research is needed to better understand the various components and players of implementation interventions, how to overcome barriers to implementation, effectiveness of implementation interventions, and on implementation outcomes and their measurement. Once a program of care is successfully implemented, the ultimate goal is to determine whether it improves important patient outcomes such as recovery and return to duty.

Chiropractic Integration Within a Community
Health Centre: A Cost Description and
Partial Analysis of Cost-utility from
the Perspective of the Institution

J Can Chiropr Assoc. 2019 (Aug); 63 (2): 64-79 ~ FULL TEXT

This study evaluated the cost-utility of chiropractic integration for low back pain services within a primary care CHC setting from the perspective of the healthcare institution. Among the subjects followed in this study, the addition of chiropractic care to usual medical care was associated with improved outcomes at a reasonable cost. These outcomes, along with the potential cost savings of such integration, may have important implications for healthcare institutions and their patients, as well as for policy decision-makers and other health stakeholders. Future comparative cost and effectiveness studies with control of confounding are nevertheless needed to evaluate the impact of chiropractic care with or without usual medical care in these settings.

Care for Low Back Pain:
Can Health Systems Deliver?

Bulletin of the World Health Organization 2019 (Jun 1); 97 (6): 423–433 ~ FULL TEXT

Delivery of guideline-concordant care for low back pain requires system-wide changes. Strong governance at each level of the health system will be key to redefining how society views and manages low back pain. Health systems should prioritize policies that: empower clinicians and consumers to make well-informed choices; encourage clinicians to deliver the right care to those who need it most; provide financial support to evidence-based non-pharmacological treatment; and regulate the influence of those with vested interests in the current situation. Small adjustments to health policy will not work in isolation. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change. Addressing system-level barriers to guideline-based care could be cost-neutral; every year health systems waste billions of dollars on unnecessary tests and treatments for low back pain. Although disinvestment is difficult, redistributing funds to support guideline-concordant care is a promising way forward. Because current approaches to treatment often lack formal evidence, we strongly encourage careful evaluation of any new approach to funding or service delivery.

Group and Individual-level Change on
Health-related Quality of Life in
Chiropractic Patients With Chronic
Low Back or Neck Pain

Spine (Phila Pa 1976) 2019 (May 1); 44 (9): 647–651 ~ FULL TEXT

The results of this study contribute to the literature by providing evidence that chiropractic care is associated with improvements in functioning and well-being among individuals with chronic low back or neck pain. The study findings provide empirical verification of why some chronic pain patients utilize chiropractic care on a regular basis. It supports the use of chiropractic care as one option for improving functioning and well-being of patients with chronic low back pain or neck pain. While we are unable to infer the underlying mechanism for the observed improvements in patients, spinal manipulation is designed to relieve pain and improve physical functioning. Studies of the biomechanics indicate that spinal manipulation produces reflex responses and movements of vertebral bodies in the para-physiologic zone. [27]

Self-reported Use of Family Physician, Chiropractor
and Physiotherapy Services Among Adult Canadians
with Chronic Back Disorders:
An Observational Study

BMC Health Serv Res 2018 (Dec 17); 18 (1): 970 ~ FULL TEXT

This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations. The identified gaps in access to care among certain population groups demonstrates that there is not equitable access to care among Canadians with CBD. Enhancing access to potentially beneficial non-physician services for people with CBD requires rethinking the way front-line back care is delivered in Canada, including pressure on insurers and policy makers to cover and enable greater access to non-pharmacological management treatment options that have demonstrated value. [34, 40]

Cost-effectiveness of Spinal Manipulation, Exercise,
and Self-management for Spinal Pain Using an
Individual Participant Data Meta-analysis
Approach: A Study Protocol

Chiropractic & Manual Therapies 2018 (Nov 13); 26: 46 ~ FULL TEXT

Combined analyses of economic data are rarely possible due to differences in resource utilization outcomes, costs and healthcare settings. [56, 57] Additionally, individual clinical trials rarely include a sufficient number of participants to detect important differences in economic outcomes. This project represents a unique opportunity to potentially combine clinical and economic data collected in eight randomized clinical trials using an IPDMA approach. This will provide more precise estimates of the cost-effectiveness of spinal manipulation, exercise therapy, and self-management compared to analysis of the individual trials. Further, an IPDMA approach has many advantages over traditional meta-analysis including the ability to conduct standardized within-study analyses, account for missing data at the individual level, and investigate potential sub-group effects at the participant level which may account for heterogeneity in estimates across studies. [52]

Long-term Relief from Tension-type Headache and
Major Depression Following Chiropractic Treatment

J Family Med Prim Care 2018 (May); 7 (3): 629–631 ~ FULL TEXT

We report the case of a 44-year-old school teacher who experienced long-term relief from tension-type headache (TTH) and major depression following chiropractic treatment. It is well recognized that psychiatric comorbidity and suicide risk are commonly found in patients with painful physical symptoms such as chronic headache, backache, or joint pain. Recent studies indicated that autonomic dysfunction plays a role in the pathogenesis of TTHs and depressive disorders. The autonomic nervous system is mainly controlled by reflex centers located in the spinal cord, brain stem, and hypothalamus. This report highlights the rewarding outcomes from spinal adjustment in certain neuropsychiatric disorders. Long-term results of chiropractic adjustment in this particular case were very favorable. Further studies with larger groups are warranted to better clarify the role of chiropractic.

Primary Care Management of Non-specific Low Back Pain:
Key Messages from Recent Clinical Guidelines

Medical J Australia 2018 (Apr 2); 208 (6): 272–275 ~ FULL TEXT

Changes in management as a result of the guidelines:

  • emphasising simple first line care with early follow-up;

  • encouraging non-pharmacological treatments over pharmacological treatments; and

  • recommending against the use of surgery, injections and denervation procedures.

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

Mayo Clin Proc Innov Qual Outcomes. 2017 (Oct 19); 1 (3): 226–233 ~ FULL TEXT

These findings support that initiating care with a nonpharmacological provider for a new episode of neck pain may present an opportunity to decrease opioid exposure (DC and PT) and advanced imaging and injections (DC only). Although these findings need confirmation in a better controlled study, our results suggest that adopting such a strategy aligns well with recent CDC and ACP recommendations and has the potential to decrease the management burden of neck pain by PCPs. Future research is needed to examine the association of patient-centered outcomes and health care utilization and to explore whether seeking care from a nonpharmacological provider is also associated with cost savings in addition to decreased health care utilization.

Association Between the Type of First Healthcare
Provider and the Duration of Financial Compensation
for Occupational Back Pain

J Occupational Rehabilitation 2017 (Sep);   27 (3):   382-392 ~ FULL TEXT

The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.
Refer to our extensive collection on: Workers' Compensation

Complementary and Integrative Medicine
in the Management of Headache

British Medical Journal 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).

Chiropractic Spinal Manipulative Therapy For
Migraine: A Three-Armed, Single-Blinded,
Placebo, Randomized Controlled Trial

European Journal of Neurology 2017 (Jan);   24 (1):   143–153 ~ FULL TEXT

The blinding was strongly sustained throughout the RCT, adverse events (AEs) were few and mild, and the effect in the chiropractic spinal manipulative therapy (CSMT) and placebo group was probably a placebo response. Because some migraineurs do not tolerate medication because of AEs or co-morbid disorders, CSMT might be considered in situations where other therapeutic options are ineffective or poorly tolerated.

The Cost-Effectiveness Triumvirate

Variations in Patterns of Utilization and Charges
for the Care of Headache in North Carolina,
2000-2009: A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   229-239 ~ FULL TEXT

Overall utilization and average charges for the treatment of headache increased considerably from 2000 to 2005 and then decreased in each subsequent year. Policy changes that took place between 2005 and 2007 may have affected utilization rates of certain providers and their associated charges. MD care accounted for the majority of total allowed charges throughout the decade. In general, patterns of care involving multiple providers and referral care incurred the largest charges, whereas patterns of care involving single or nonreferral providers incurred the least charges. MD-only, DC-only, and MD-DC care were the least expensive patterns of headache care; however, risk-adjusted charges (available 2006-2009) were significantly lower for DC-only care compared with MD-only care.

Variations in Patterns of Utilization and Charges
for the Care of Neck Pain in North Carolina,
2000 to 2009: A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   240-251 ~ FULL TEXT

Increases in utilization and charges were the highest among patterns involving MDs, PTs and referral providers.   These findings are consistent with previous studies showing that medical specialty, diagnostic imaging, and invasive procedures (eg, spine injections, surgery) [17, 19, 20, 21] are significant drivers of increasing spine care costs.   When costs are viewed vertically as if in "silos" (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population.   This is an opportunity to view costs laterally versus a confined, vertical analysis.

Variations in Patterns of Utilization and Charges
for the Care of Low Back Pain in North Carolina,
2000 to 2009: A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   252-262 ~ FULL TEXT

A major strength of the study was the large amount of low back pain claims made available to us for analysis. The data were from 3,159,362 claims generated by approximately 66,0000 persons over the 2000-2009 decade in North Carolina, in several different pathways of healthcare services. This study and the series of papers it has generated on the treatment of low back pain, neck pain [25] and headache, [26] provides unique economic examination for healthcare policy makers and legislators.   When costs are viewed vertically as if in "silos" (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population.   This is an opportunity to view costs laterally versus a confined, vertical analysis.

Cross-Sectional Analysis of Per Capita Supply
of Doctors of Chiropractic and Opioid Use
in Younger Medicare Beneficiaries

J Manipulative Physiol Ther. 2016 (May);   39 (4):   263–266 ~ FULL TEXT

In this exploratory analysis, we found a strong inverse correlation between the per-capita supply of DCs and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Further, we found a strong inverse correlation between the per-capita spending on CMT and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Based upon our findings, we suggest that Medicare consider promoting a trial of CMT prior to use of conventional medical care for patients with neck or back pain. The rationale for use of CMT prior to medical care is that concurrent medical care might result in opioid prescriptions; however, further study that examines opioid use when CMT and conventional medical care are concurrently provided is warranted.

Importance of the Type of Provider Seen to Begin
Health Care for a New Episode Low Back Pain:
Associations with Future Utilization and Costs

J Eval Clin Pract. 2016 (Apr); 22 (2): 247–252 ~ FULL TEXT

The RESULTS portion of this Abstract only partially discusses the findings, comparing 3 different professions' treatment, costs, and outcomes for low back pain.   In it they only mention the costs associated with medical management, while in reviewing chiropractic care vs. physical thereapy portions, they choose to emphasize:

Entry in chiropractic was associated with
an increased episode of care duration

Entry in physical therapy
no patient entering in physical therapy had surgery.

That *seems* to suggest that physical therapy *may* entail less expense, or shorter durations of care, or that chiropractic patients are more likely to end up with surgery.   None of that is true.   Their own Table 2 plainly reveals that chiropractic care was the least expensive form of care provided to the 3 groups.

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

J Manipulative Physiol Ther. 2016 (Feb); 39 (2): 63–75 ~ FULL TEXT

After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT 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; order was irrelevant when both CMT and medical treatment were provided.

Initial Integration of Chiropractic Services
into a Provincially Funded Inner City
Community Health Centre:
A Program Description

J Can Chiropr Assoc 2015 (Dec); 59 (4): 363–372 ~ FULL TEXT

Chiropractic services are being utilized by patients, and referring providers. Clinical outcomes indicate that services rendered decrease musculoskeletal pain in an inner city population.

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

J Manipulative Physiol Ther. 2015 (Sep); 38 (7): 477–483 ~ FULL TEXT

JMPT's Editor-in-Chief Claire Johnson, DC, MEd, emphasized the importance of the latest findings:
“Comparative studies – in other words, research that compares the outcomes between two different providers or modalities – are rare for chiropractic care,” she said.   “Thus, this study by Houweling, et al., is especially important if payers and policy-makers are to better understand the 'triple aim' as it relates to chiropractic. Specifically, this study helps us better understand what type of care provides better patient satisfaction, is more cost effective, and improves population health.”

Regional Supply of Chiropractic Care and Visits
to Primary Care Physicians for Back and Neck Pain

J American Board of Family Medicine 2015 (Jul); 28 (4): 481–490 ~ FULL TEXT

Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11–14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services. When extrapolated to the nation (based on our predictions from our adjusted model), we estimate that chiropractic care is associated with a reduction of 0.37 million visits to PCPs for back and/or neck pain at a total cost of $83.5 million (Table 3).

Chiropractic Use in the Medicare Population:
Prevalence, Patterns, and Associations With
1-Year Changes in Health and
Satisfaction With Care

J Manipulative Physiol Ther. 2014 (Oct); 37 (8): 542–551 ~ FULL TEXT

This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

Conservative Spine Care: Opportunities to
Improve the Quality and Value of Care

Popul Health Manag. 2013 (Dec); 16 (6): 390-396 ~ FULL TEXT

A previous article analyzed current practices regarding the use of coronary stents in the chronic stable angina patient. [4] Musculoskeletal disorders represent another diagnostic class that, while usually not life threatening, results in a high prevalence of morbidity and significant societal burden. [5] Low back pain (LBP) management in particular has been linked to inefficiency and waste. [6] This is likely related, in part, to the growing list of treatment approaches recommended for conservative care (pharmacologic and non-pharmaceutical options) and the difficulty in determining the best option for each patient. [7]

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

Spine (Phila Pa 1976). 2013 (May 15); 38 (11): 953-964 ~ FULL TEXT

Significant worker baseline variables in a multivariate model predicting one or more lumbar spine surgeries within 3 years of claim submission included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and first seeing a surgeon for the injury. Participants younger than 35 years, females, Hispanics, and participants whose first visit for the injury was to a chiropractor had lower odds of surgery.

Chiropractic Episodes and the Co-occurrence
of Chiropractic and Health Services Use
Among Older Medicare Beneficiaries

J Manipulative Physiol Ther 2012 (Mar);   35 (3):   168–175 ~ FULL TEXT

Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

Effectiveness of Manual Therapy for Chronic
Tension-type Headache: A Pragmatic,
Randomised, Clinical Trial

Cephalalgia. 2011 (Jan); 31 (2): 133–143 ~ FULL TEXT

After 8 weeks (n = 80) and 26 weeks (n = 75), a significantly larger reduction of headache frequency was found for the manual therapy (MT) group (mean difference at 8 weeks, -6.4 days; 95% CI -8.3 to -4.5; effect size, 1.6). Disability and cervical function showed significant differences in favour of the MT group at 8 weeks but were not significantly different at 26 weeks.   Manual therapy is more effective than usual GP care in the short- and longer term in reducing symptoms of chronic tension-type headache (CTTH).

Cost of Care for Common Back Pain Conditions
Initiated with Chiropractic Doctor vs
Medical Doctor/Doctor of Osteopathy as
First Physician: Experience of One
Tennessee-Based General Health Insurer

J Manipulative Physiol Ther 2010 (Nov); 33 (9): 640-643 ~ FULL TEXT

Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient's costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. This clearly demonstrates the savings that are possible when a patient is permitted to choose a chiropractor, rather than an MD for their care.

Interventions to Improve Adherence to Exercise
for Chronic Musculoskeletal Pain in Adults

Cochrane Database Syst Rev 2010 (Jan 20);   2010 (1):   CD005956 ~ FULL TEXT

Authors' conclusions:

  • The type of exercise prescribed does not appear to influence levels of exercise adherence. Patient preference should therefore be considered in an attempt to increase motivation to initiate and maintain an exercise programme

  • Including simple educational and behavioural strategies, such as providing feedback or using an exercise contract, as part of routine delivery of exercise for chronic musculoskeletal pain may enhance adherence

  • Providing supervised exercise, follow up to reinforce exercise behaviour, and supplementing face-to-face instruction with other material all may have a positive influence on levels of exercise adherence

  • Although supplementing home exercise with a group exercise programme may improve overall physical activity levels, attendance at group sessions may be limited if session times are inconvenient, and missed sessions cannot be rescheduled. The type of exercise setting should therefore again be directed by patient preference

Do Chiropractic Physician Services for Treatment
of Low-Back and Neck Pain Improve the Value of
Health Benefit Plans? An Evidence-Based
Assessment of Incremental Impact on
Population Health and Total Health Care Spending

Mercer Health and Benefits LLC (October 12, 2009) ~ FULL TEXT

This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.

Effects of a Managed Chiropractic Benefit on the
Use of Specific Diagnostic and Therapeutic
Procedures in the Treatment of
Low Back and Neck Pain

J Manipulative Physiol Ther 2005 (Oct); 28 (8): 564–569 ~ FULL TEXT

For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a significant reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

An Evaluation of Medical and Chiropractic
Provider Utilization and Costs: Treating
Injured Workers in North Carolina

J Manipulative Physiol Ther 2004 (Sep); 27 (7): 442-448 ~ FULL TEXT

These data, with the acknowledged limitations of an insurance database, indicate lower treatment costs, less workdays lost, lower compensation payments, and lower utilization of ancillary medical services for patients treated by DCs. Despite the lower cost of chiropractic management, the use of chiropractic services in North Carolina appears very low.

Patient Attitudes, Insurance, and Other Determinants
of Self-referral to Medical and
Chiropractic Physicians

Am J Public Health 2003 (Dec); 93 (12): 2111–2117 ~ FULL TEXT

Chiropractic and other forms of alternative medicine are being increasingly integrated into managed care, at least partly in response to patient preferences. [31, 35, 36] With evidence of differences in costs and some outcome measures (e.g., satisfaction) of low back treatment by provider type, [37–42] a patient’s choice of provider can promote economic efficiency or hinder it. Our results highlight the importance of patients’ attitudes, health status, and third-party payment in self-referral decisions. In particular, by drawing attention to the role of patient attitudes in self-referral, our work highlights the potential role of education as an indirect way to influence attitudes and thus encourage more cost-effective choices.

Cost Effectiveness of Physiotherapy, Manual Therapy,
and General Practitioner Care for Neck Pain:
Economic Evaluation Alongside a
Randomised Controlled Trial

British Medical Journal 2003 (Apr 26); 326 (7395): 911 ~ FULL TEXT

A hands-on approach to treating neck pain by manual therapy may help people get better faster and at a lower cost than more traditional treatments, according to this study.   After seven and 26 weeks, they found significant improvements in recovery rates in the manual therapy group compared to the other 2 groups. For example, at week seven, 68% of the manual therapy group had recovered from their neck pain vs. 51% in the physical therapy group and 36% in the medical care group.
You may also enjoy this WebMD review (Thursday, April 24, 2003) titled:
Manual Therapy Eases Neck Pain, Cheaply: Hands-On Approach Effective,
and More Cost-Effective, than Traditional Treatments

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

Annals of Internal Medicine 2002 (May 21); 136 (10): 713–722 ~ FULL TEXT

In this randomized, controlled trial, researchers compared the effectiveness of manual therapy, physical therapy (PT) and continued care by a general practitioner (GP) in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) compared to the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Additionally, patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. The magnitude of the differences between manual therapy and the other treatments (PT or GP) was most pronounced for perceived recovery.

Behavioral and Physical Treatments for
Tension-type and Cervicogenic Headache

Duke University Evidence-based Practice Center ~ 2001 ~ FULL TEXT
In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches.
  You might also enjoy Dr. Anthony Rosner's discussion
You may download the full 10-page Adobe Acrobat (PDF) version.
You will also enjoy
FCER's announcement on the initial publication of the Duke Report

Cost-effectiveness Studies of Medical and
Chiropractic Care for Occupational Low
Back Pain. A Critical Review
of the Literature

Spine J. 2001 (Mar); 1 (2): 138-147 ~ FULL TEXT

The current literature suggests that chiropractors and physicians provide equally effective care for OLBP but that chiropractic patients are more satisfied with their care. Evidence on the relative costs of medical and chiropractic care is conflicting. Several methodological deficiencies limit the validity of the reviewed studies. No studies combine high-quality cost data with adequate sample sizes and controls for confounding factors.

The Outcomes and Costs of Care for Acute Low
Back Pain Among Patients Seen by Primary
Care Practitioners, Chiropractors, and
Orthopedic Surgeons

New England J Medicine 1995 (Oct 5); 333 (14): 913–917 ~ FULL TEXT

The status at six months was ascertained for 1,555 of the 1,633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors.


Reference Materials

Cost-Effectiveness of Chiropractic
A Chiro.Org article collection

Take a close look at the 3 Cost-Effectiveness Triumvirate articles, as they detail how other studies have under-valued chiropractic care, by simply ignoring other medical and social costs, like extended unemoployment, drug costs and side-effects, and referred care patterns. They are a real eye-opener.

Chronic Neck Pain and Chiropractic
A Chiro.Org article collection

This section contains articles going back to the early 90s, and also provides an impressive Reference Materials section.

Low Back Pain and Chiropractic
A Chiro.Org article collection

This section contains articles going back to 1985, and also provides some helpful sub-sections on Patient Expectations of Relief, the Trajectories of Low Back Pain and a detailed section on What is Usual (medical) Care? .

Headache and Chiropractic
A Chiro.Org article collection

This section contains articles going back to 1988, and also provides some helpful sub-sections on the sub-types of headaches, including Cervicogenic, Chronic Tension, and Migraine Headache.

Chiropractic Care For Veterans
A Chiro.Org article collection

Enjoy this collection of articles by DCs who treat our Vets, going back to 2002. It ALSO contains a section with the collected Congressional Acts and Veterans Affairs Documents as a reference.

Workers' Compensation and Chiropractic
A Chiro.Org article collection

Studies going back to the 1980s reveal that chiropractic care gets workers back to work faster and cheaper than standard medical care. Drop by and enjoy this new topical collection.

Non-pharmacologic Therapy and Chiropractic
A Chiro.Org article collection

Onc of the few silver linings in the Opioid Epidemic storm cloud was the studies looking at which patients ended up being swallowed by opioid addiction. Chiropractic is an effective approach for managing musculoskeletal pain, and that has saved many of them from starting down that dark path.





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