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

Exercise + Chiropractic Chiropractic Rehab Integrated Care

Headache Adverse Events Disc Herniation

Chronic Neck Pain Low Back Pain Whiplash Section

Conditions That Respond Alternative Medicine Approaches to Disease

Integrated Health Care Articles

Racial and Ethnic Variation in Complementary
and Integrative Health Therapy Use
Among US Veterans

JAMA Netw Open 2023 (Jun 1); 6 (6): e2318020 ~ FULL TEXT

This large-scale, cross-sectional study found racial and ethnic differences in use of 4 of 5 CIH therapies among VA health care system users when not considering their medical facility location. Given those differences mostly disappeared once medical facilities were accounted for, the results demonstrated the importance of considering facilities and residential locations when examining racial differences in CIH therapy use. Medical facilities could be a proxy for the racial and ethnic composition of their patients, CIH therapy availability, regional patient or clinician attitudes, or therapy availability.

Chiropractors in Interprofessional Practice
Settings: A Narrative Review Exploring
Context, Outcomes, Barriers
and Facilitators

Chiropractic & Manual Therapies 2022 (Dec 16); 30: 56 ~ FULL TEXT

Data suggests that incorporating chiropractors into community health and sports medicine interprofessional practice interventions is achievable and appears to impact collaborative practice positively. For older adults with low back pain, quality of life and care-related satisfaction are potential relevant outcomes for the evaluation of interprofessional practice interventions. There is currently very limited evidence from which to judge the value of interprofessional practice interventions, as available literature appears to focus mainly on interprofessional collaboration. Studies conducted specifically to evaluate interprofessional practice solutions and addressing specific health care issues or practice domains are urgently required.

Increased Utilization of Spinal Manipulation by
Chiropractors to Tackle the Opioid Epidemic

Medical Care 2021 (Aug 25) [EPUB] ~ FULL TEXT

Increased utilization of spinal manipulation performed by chiropractors may be one approach to dampening the opioid epidemic through practices that minimize the use of those drugs for conditions like low back pain where opioid prescribing remains high. [1] Opioids have been found to be ineffective for low back pain while causing multiple side effects such as addiction, drug diversion, and overdose. [2] In response to the opioid epidemic, over half of the states have made legislative changes limiting the quantity and duration of opioid prescriptions for acute pain. [3] In addition, the American College of Physicians has recommended spinal manipulation as part of the nonpharmacological firstline treatment for low back pain since 2017. [4] Efforts such as these have been impactful.

When Boundaries Blur - Exploring Healthcare Providers' Views
of Chiropractic Interprofessional Care and the
Canadian Forces Health Services

J Can Chiropr Assoc 2021 (Apr); 65 (1): 14–31 ~ FULL TEXT

Our study provides the first qualitative analysis of barriers and opportunities for the collaboration of chiropractic within the unique CFHS environment. This manuscript, exploring IPC relative to MSK conditions in the CFHS, elucidated barriers and opportunities to potentially inform a series of next steps involving key stakeholders. Further, findings reinforce the importance of bringing CAF members’ voices to this important work.

Based upon our qualitative analysis, the research team posits the following recommendations gleaned from the over-arching experiences, perceptions, meanings and interpretations shared by key informants, together with reflexivity of the researchers, and an in-depth description and interpretation of the research problem. Our recommendations are:

Doctors of Chiropractic Working with or within
Integrated Healthcare Delivery Systems:
A Scoping Review Protocol

BMJ Open 2021 (Jan 25); 11 (1): e043754~ FULL TEXT

Musculoskeletal conditions, including back and neck pain, are the leading causes of disability worldwide. [1] In the USA, the use of pharmacological treatments, such as opioids and invasive procedures, such as steroid injections and surgery, for low back pain, increased from 1997 to 2010. [2] During the same time period disability and costs from low back pain also increased. [2, 3] In contrast to these patterns of care for spinal disorders, clinical practice guidelines emphasise the use of non-pharmacological approaches before the use of over the counter medications, prescribed medications or invasive procedures. [4–7] Yet patients who seek care in integrated healthcare delivery systems, at specific medical settings such as primary care clinics in hospitals or community health centres, still frequently receive prescribed medications as first line care. [8, 9] Limited familiarity with the efficacy and role of non-pharmacological treatments, few opportunities to practise in the same location as non-pharmacological providers, and inadequate channels of communication between these providers have been identified as important clinician-level barriers that prevent referrals to non-pharmacological treatments. [10–12] Increasing collaboration between primary care providers and providers of non-pharmacological treatment will improve access to non-pharmacological treatments and may improve outcomes.

Implementation of the Primary Spine Care Model in a
Multi-Clinician Primary Care Setting:
An Observational Cohort Study

J Manipulative Physiol Ther 2020 (Sep); 43 (7): 667–674 ~ FULL TEXT

Among patients with spine-related disorders (SRDs) included in this study, implementation of the primary spine care (PSC) model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.

Complementary, Integrative, and Nondrug Therapy Use for Pain
Among US Military Veterans on Long-term Opioids

Medical Care 2020 (Sep); 58 Supp l 2 9S: S116–S124 ~ FULL TEXT

In conclusion, our study found that US VA patients on long-term opioid therapy (LTOT) for chronic pain commonly use nondrug therapies to manage pain, that observed nondrug therapy use classes reflect clinically relevant functional groups, and that patient characteristics are associated with use of different nondrug therapies. Further exploration of factors affecting nondrug therapy access and use for specific subpopulations, such as use of exercise/movement therapy by people with high pain interference, may enable implementation of nondrug and complementary and integrative health (CIH) therapy for chronic pain and expand safe, effective pain treatment options for people prescribed LTOT.

Integrating a Multidisciplinary Pain Team and Chiropractic
Care in a Community Health Center: An Observational
Study of Managing Chronic Spinal Pain

J Primary Care & Community Health 2020 (Sep 10)~ FULL TEXT

This observational study within a community health center resulted in improvement in spinal pain and disability with chiropractic care versus a multidisciplinary pain team. Offering similar services in primary care may help to address pain and disability, and hopefully limit external referrals, advanced imaging, and opioid prescriptions.

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.

Stakeholder Expectations from the Integration of Chiropractic
Care into a Rehabilitation Setting: A Qualitative Study

BMC Complementary and Alternative Medicine 2018 (Dec 4); 18 (1): 316 ~ FULL TEXT

Stakeholders expected the addition of chiropractic care to a rehabilitation specialty hospital to benefit patients through pain management and functional improvements leading to whole person healing. They also expected chiropractic to benefit the healthcare team by facilitating other therapies in pursuit of the hospital mission, that is, moving patients towards discharge. Understanding stakeholder expectations may allow providers to align current expectations with what may be reasonable, in an effort to achieve appropriate clinical outcomes and patient and staff satisfaction.

Chiropractic Integration into Private Sector
Medical Facilities: A Multisite Qualitative Case Study

J Altern Complement Med. 2018 (Aug); 24 (8): 792–800 ~ FULL TEXT

These nine medical facilities had unique organizational structures and reasons for initiating chiropractic care in their settings. Across sites, DCs were sought to take an evidence-based approach to patient care, work collaboratively within a multidisciplinary team, engage in interprofessional case management, and adopt organizational mission and values. Chiropractic clinics were implemented within existing human resources, physical plant, information technology, and administrative support systems, and often expanded over time to address patient demand. DCs usually were co-located with medical providers and integrated into the collaborative management of patients with musculoskeletal and co-morbid conditions. Delivery of chiropractic services was perceived to have high value among patients, medical providers, and administration. Patient clinical outcomes, patient satisfaction, provider productivity, and cost offset were identified as markers of clinic success.

Be Good, Communicate, and Collaborate: A Qualitative Analysis
of Stakeholder Perspectives on Adding a Chiropractor
to the Multidisciplinary Rehabilitation Team

Chiropractic & Manual Therapies 2018 (Jun 22); 26: 29 ~ FULL TEXT

Our qualitative study provides a description of the professional and personal qualities preferred in a chiropractor by patients, families, clinical staff, and other stakeholders in an in-patient, rehabilitation setting. Study participants supported the addition of a chiropractor to the multidisciplinary team who practiced in a safe, evidence-based, patient-centered manner. Interprofessional skills that enhanced teamwork, intrapersonal qualities to support patients’ emotional journeys through the rehabilitation process, and an organizational perspective that amplified the mission of the institution also were desired. Rather than labeling stakeholder perceptions as good, bad or indifferent as in previous studies, these results highlight specific attributes chiropractors might cultivate to enhance patient outcomes and their experience of healthcare, influence clinical decision-making and interprofessional teamwork, and impact healthcare organizations. Chiropractic education might emphasize the development of such qualities in students who anticipate working in such collaborative care settings.

Integration of Doctors of Chiropractic Into Private
Sector Health Care Facilities in the United States:
A Descriptive Survey

J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 149–155 ~ FULL TEXT

The response rate was 76% (n = 38). Most respondents were men and mid-career professionals with a mean 21 years of experience in chiropractic. Doctors of chiropractic reported working in hospitals (40%), multispecialty offices (21%), ambulatory clinics (16%), or other (21%) health care settings. Most (68%) were employees and received salary compensation (59%). The median number of DCs per setting was 2 (range 1-8). Most DCs used the same health record as medical staff and worked in the same clinical setting. More than 60% reported co-management of patients with medical professionals. Integrated DCs most often received and made referrals to primary care, physical medicine, pain medicine, orthopedics, and physical or occupational therapy. Although in many facilities the DCs were exclusive providers of spinal manipulation (43%), in most, manipulative therapies also were delivered by physical therapists and osteopathic or medical physicians. Informal face-to-face consultations and shared health records were the most common communication methods.

Chiropractic Integrated Care Pathway for Low Back Pain
in Veterans: Results of a Delphi Consensus Process

J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 137–148 ~ FULL TEXT

The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers.

Management of Back Pain-related Disorders in a Community
With Limited Access to Health Care Services:
A Description of Integration of
Chiropractors as Service Providers

J Manipulative Physiol Ther. 2017 (Nov); 40 (9): 635–642 ~ FULL TEXT

Questionnaire data were obtained from 93 patients. The mean age of the sample was 49.0 ± 16.27 years, and 66% were unemployed. More than three-quarters (77%) had had their back pain for more than a month, and 68% described it as constant. According to the Bournemouth Questionnaire, Bothersomeness, and global improvement scales, a majority (63%, 74%, and 93%, respectively) reported improvement at discharge, and most (82%) reported a significant reduction in pain medication. More than three-quarters (77%) did not visit their primary care provider while under chiropractic care, and almost all (93%) were satisfied with the service. According to the EuroQol 5 Domain questionnaire, more than one-third of patients (39%) also reported improvement in their general health state at discharge. Implementation of an integrated chiropractic service was associated with high levels of improvement and patient satisfaction in a sample of patients of low socioeconomic status with subacute and chronic back pain.

Pediatric Integrative Medicine
Pediatrics. 2017 (Sep); 140 (3): e20171961 ~ FULL TEXT

The American Academy of Pediatrics is dedicated to optimizing the well-being of children and advancing family-centered health care. Related to this mission, the American Academy of Pediatrics recognizes the increasing use of complementary and integrative therapies for children and the subsequent need to provide reliable information and high-quality clinical resources to support pediatricians. This Clinical Report serves as an update to the original 2008 statement on complementary medicine. The range of complementary therapies is both extensive and diverse. Therefore, in-depth discussion of each therapy or product is beyond the scope of this report. Instead, our intentions are to define terms; describe epidemiology of use; outline common types of complementary therapies; review medicolegal, ethical, and research implications; review education and training for select providers of complementary therapies; provide educational resources; and suggest communication strategies for discussing complementary therapies with patients and families.

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
Managementof 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 ~ FULL TEXT

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 ~ FULL TEXT

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.

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.

A Survey of American Chiropractic Association Members'
Experiences, Attitudes, and Perceptions of Practice
in Integrated Health Care Settings

J Chiropractic Medicine 2015 (Dec); 14 (4): 227–239 ~ FULL TEXT

The survey was completed in 2011 by 1142 respondents, for a response rate of 11.8%. The majority of respondents (82.9%) did not currently practice in an integrated setting, whereas 17.1% did. Those practicing in various integrated medical settings reported delivering a range of diagnostic, therapeutic, and case management services. Participation in administrative and scholarly activities was less common. Respondents not practicing in integrated settings reported being interested in delivering a very similar array of clinical services. Doctors of chiropractic practicing in hospital or outpatient medical facilities reported frequent engagement in interprofessional collaboration. Both nonintegrated and integrated respondents reported very similar educational interests on a range of clinical topics.

Collaborative Care for a Patient with Complex Low Back
Pain and Long-term Tobacco Use: A Case Report

J Can Chiropr Assoc. 2015 (Sep); 59 (3): 216–225 ~ FULL TEXT

Few examples of interprofessional collaboration by chiropractors and other healthcare professionals are available. This case report describes an older adult with complex low back pain and longstanding tobacco use who received collaborative healthcare while enrolled in a clinical trial. A doctor of chiropractic and a doctor of osteopathy provided collaborative care based on patient goal setting and supported by structured interdisciplinary communication, including record sharing and telephone consultations. Collaborative care facilitated active involvement of the patient and resulted in decreased radicular symptoms, improvements in activities of daily living, and tobacco use reduction.

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

J 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.

Integrative Therapies for Low Back Pain That
Include Complementary and Alternative
Medicine Care: A Systematic Review

Glob Adv Health Med. 2014 (Sep); 3 (5): 49–64 ~ FULL TEXT

Patients often try an integrated approach for treatment of LBP, using a combination of conventional medical care and CAM modalities. Previous systematic reviews have examined the use of individual CAM modalities for LBP and found promising results. This systematic review sought to determine if an integrated approach that includes different CAM therapies or CAM therapies combined with conventional medical care is more effective for the management of LBP than either alone. The studies found support the conclusion that integrated therapy which includes SMT combined with exercise therapy and acupuncture combined with conventional medical care or with exercise therapy appears to be more effective than select single therapies alone for treating LBP, although many questions remain. More studies are needed as most of the articles included participants with chronic LBP and there is a lack of RCTs for many CAM modalities used in an integrated manner. Further research into the integrated management of LBP is clearly needed to provide better guidance for patients and clinicians, as is the development of researchers with expertise in CAM modalities. In particular, there is a need for long-term studies that use cost effectiveness in addition to pain and disability from LBP as outcomes.

Perspectives of Older Adults on Co-management of Low Back Pain
by Doctors of Chiropractic and Family Medicine Physicians:
A Focus Group Study

BMC Complement Altern Med. 2013 (Sep 16); 13: 225 ~ FULL TEXT

Low back pain (LBP) is a leading cause of disability
nd disease burden. [1, 2] People age 65 years and older report a 25% monthly LBP prevalence rate [3, 4] with recurrent or debilitating LBP common in older populations. [4–6] Chronic LBP is linked to difficulties with activities of daily living (ADLs) [7, 8], depression [4, 7, 9, 10], sleep problems [7, 9], and decreased performance on physical function [7, 11] and neuropsychological tests. [11] An estimated 2.3% of annual physician visits in the U.S. are for LBP. [3] Persons with LBP and other spine conditions have increased healthcare expenditures for medications, spinal imaging, injections and surgery [3, 4, 9, 12–14]. Medicare charges among older adults with back disorders have demonstrated significant increases for patient visits, imaging and spinal injections [12, 15] without translation to better health outcomes for LBP patients. [13–15]

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

J 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.

Individualized Chiropractic and Integrative Care for Low
Back Pain: A Randomized Clinical Trial
BMC Complementary and Alternative Medicine 2012 (Jun 12); 12; 185

Two hundred patients participated. Mixed model longitudinal analysis showed that the integrative care group had statistically significant more pain reduction, perceived global improvement and satisfaction with care in both the short- (up to 12 weeks) and long-term (through 52 weeks; p≤ 0.05). The group differences were relatively small.

A Model of Integrative Care for Low-back Pain
J Altern Complement Med. 2012 (Apr); 18 (4): 354–362 ~ FULL TEXT

Historically, federal agencies including the National Institutes of Health, the Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid, the Department of Defense, and the Veterans Administration have not sponsored research aimed at evaluating the cost effectiveness — or lack thereof — of emerging models of multidisciplinary, “integrative care” in the treatment of common medical conditions. This study argues that such comparative effectiveness research in this area is feasible, promising, and warranted, at least with regard to adults with persistent LBP.

Will Shared Decision Making Between Patients with
Chronic Musculoskeletal Pain and Physiotherapists,
Osteopaths and Chiropractors Improve Patient Care?

Fam Pract. 2012 (Apr); 29 (2): 203–212 ~ FULL TEXT

Seeking care for any condition is not static but a process particularly for long-term conditions such as chronic musculoskeletal pain (CMP). This may need to be taken into account by both CMP patients and their treating health professionals, in that both should not assume that their views about causation and treatment are static and that instead they should be revisited on a regular basis. Adopting a shared decision-making approach to treatment may be useful particularly for long-term conditions; however, in some cases, this may be easier said than done due to both patients' and health professionals' sometimes discomfort with adopting such an approach. Training and support for both health professionals and patients may be helpful in facilitating a shared decision-making approach.

Complementary and Alternative Medicine Use
Among Veterans with Chronic Noncancer Pain

J Rehabil Res Dev. 2011; 48 (9): 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.

Designing a Framework for the Delivery of Collaborative
Musculoskeletal Care Involving Chiropractors and
Physicians in Community-based Primary Care

J Interprof Care. 2010 (Nov); 24 (6): 678–689 ~ FULL TEXT

Physicians, chiropractors, and patients participating in focus groups generally supported a framework of collaboration to optimize the efficient and effective use of limited resources. The framework developed in this study may help to understand and promote interprofessional collaborative practice not only between physicians and chiropractors, but other health care providers in primary care. The implementation and subsequent evaluation of this proposed model should determine if it enhances interprofessional collaborative practice.

Integration of Chiropractic Services into a
Multidisciplinary Safety-Net Clinic

Topics Integr Health Care. 2010 (Sep 1); 1: 1: 1005 ~ FULL TEXT

Nearly 46 million Americans are uninsured. Health care safety-net providers are those that have a mission to offer health care to all patients, regardless of their ability to pay, and typically have a substantial number of patients who are uninsured. This paper describes the establishment of a chiropractic clinic within a free, safety-net health clinic operating in a “medical pluralism” model. In this particular collaborative arrangement, chiropractic was categorized as a specialty service, so patients were referred by the clinic’s primary care physician or nurse practitioner. Ninety one new patients were examined and treated during the first 9 months of integrating chiropractic services into the clinic. Musculoskeletal complaints, particularly low back pain (53%), extremity pain (17%) and neck pain (13%) represented the majority of the type of problems that patients presented for care. Fifty percent of the chiropractic patients were unemployed, and 77% presented with an unhealthy body mass index; 33% were current tobacco users. The first 9 months of integrating chiropractic services was viewed as successful due to consistently full patient appointment times and frequent referrals from other health care providers within the free clinic. Our challenges were almost exclusively logistical in nature. Staffing the chiropractic service was perhaps the primary challenge.

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.

Chiropractors and Collaborative Care:
An Overview Illustrated with a Case Report

J Can Chiropr Assoc. 2010 (Sep); 54 (3): 147–154 ~ FULL TEXT

Although not typical, there appears to be a growing trend of chiropractors working within collaborative care settings. We use a case report to highlight features of patient care and education related to chiropractic practice within a collaborative care model. This paper hopes to offer some insight into how a chiropractor might fit into a collaborative setting and what training might help them to function effectively. The case report used is an example where a chiropractor provided a secondary diagnosis and complementary care not previously considered by the allied team resulting in symptom control and return to work by the patient. By the nature of a chiropractor's ability to provide a primary or secondary musculoskeletal diagnosis, they have the capacity to offer an additive approach to patient care within collaborative care models. However, chiropractors wishing to work in these environments, such as a family health team, would benefit from further education.

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.

The Difference Between Integration and Collaboration in
Patient Care: Results From Key Informant Interviews
Working in Multiprofessional Health Care Teams

J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 715–722 ~ FULL TEXT

The evolution from the traditional mechanistic view of the human body to one encompassing a biopsychosocial approach has come about as a result of a greater understanding of the interrelationship between health, illness, and disease. [1-3] This view has moved the focus from the health care provider to the patient in an effort to appreciate the complexity of the multiple dimensions underlying the interplay between patient's illness and disease, thus capturing the indivisible whole of the healing relationship. [4] This inherent complexity of human health requires the involvement of individuals with disparate expertise collaborating in multidisciplinary teams to provide the best patient care. For example, the Ontario government is establishing primary health care teams across the province to provide comprehensive and coordinated care to meet the needs of patients. [5] The integration of different health services has been highlighted as a common strategy to address the delivery of effective and cost-effective comprehensive care.

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): 49–757 ~ 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): 40–748 ~ FULL TEXT

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.

Developing Integrative Primary Healthcare Delivery:
Adding a Chiropractor to the Team

Explore (NY). 2008 (Jan); 4 (1): 18–24 ~ FULL TEXT

Twelve providers were followed for the full 18 months of integration. The providers expressed increased willingness to trust the chiropractors in shared care. Questions regarding the legitimacy and effectiveness of chiropractic became increasingly positive by study end.   This project has demonstrated the successful integration of chiropractors into primary healthcare teams.

Collaborative Community-Based Teaching Clinics at the
Canadian Memorial Chiropractic College: Addressing
the Needs of Local Poor Communities

J Manipulative Physiol Ther 2007 (Oct); 30 (8): 558–565 ~ FULL TEXT

The CMCC's external clinics program has enabled access to chiropractic services to thousands of people living in the inner city and urban aboriginal communities of Toronto. This has resulted in the minimization of barriers to accessing care, the provision of appropriate and effective care, and collaboration. These clinics also greatly increase students' awareness of, sensitivity to, and commitment to being part of the solution to these problems.

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!

Chiropractic Integration or Isolation: What Price?
Robert Mootz, D.C.
Dynamic Chiropractic – October 22, 2001

Despite all of the advances and inroads our profession has made, we remain outsiders in many ways, particularly in the world of conventional health care. In the past, this was due in great measure to the ostracism of organized medicine. Today, I suspect it is primarily our own fear of success and all it might entail. As a profession, we want the accolades and rewards that mainstream recognition has to offer, but often seem to shun the responsibilities, competition, and additional work required to achieve it.

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 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.

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.

Principles in Integrative Chiropractic
J Manipulative Physiol Ther. 2003 (May);   26 (4):   254–272 ~ FULL TEXT

CAM utilization is on the rise, driven to date by public interest. Chiropractic leads in utilization of CAM therapies. There is potential for the chiropractic profession to be integrated into medical delivery systems where most medical physicians (the younger ones and the ones in primary care) already believe chiropractic is a legitimate profession providing effective care for certain conditions. Physician referrals lag behind their stated beliefs in chiropractic efficacy, however. This is due in large part to barriers, both external and internal, to communication differences and deficits. In the pursuit of greater marketing advantage, some medical groups are considering integrating chiropractic. But there are cost-benefit reasons for managing chronic and musculoskeletal pain with chiropractic care.


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).

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