THE EFFECTIVENESS AND COST-EFFECTIVENESS
OF CHIROPRACTIC MANAGEMENT OF LOW BACK-PAIN
Pran Manga, Ph.D.
Douglas E. Angus, M.A.
Costa Papadopoulos, M.H.A.
William R. Swan, B.Comm.
Funded by the Ontario Ministry of Health
The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce health care costs. It has
brought a new and unprecedented emphasis on evidence-based allocation of resources, with an overriding objective of
improving the cost-effectiveness of health care services.
The area of low-back pain (LBP) offers governments and the private sector an excellent opportunity to attain the twin
goals of greater cost-effectiveness and a major reduction in health care costs. Today LBP has become one of the most
costly causes of illness and disability in Canada - a phenomenon which does not appear to be generally appreciated or
understood in medical and government circles in Canada. Studies on the prevalence and incidence of LBP suggest that
it is ubiquitous, probably the leading cause of disability and morbidity in middle-aged persons, and by far the most
expensive source of workers' compensation costs in Ontario - as indeed in most other jurisdictions.
Much of the treatment of LBP appears to be inefficient. Evidence from Canada, the USA, the UK and elsewhere shows
that there are conflicting methods of treatment, that many of these have little if any scientific evidence of effectiveness,
that costs of treatment are very high but that despite this, levels of disability from LBP are increasing.
In the Province of Ontario LBP is managed mostly by physicians and chiropractors, with physiotherapists also playing
a significant role. While medical services are fully insured under Medicare, chiropractic care services are only partially
covered. LBP patients incur the highest out-of-pocket expenses for chiropractic services. Virtually no out-of-pocket
expenses are incurred for medical treatment, with the exception of drugs, and out-of-pocket expenses incurred for
physiotherapy services fall somewhere in between the two.
Physicians, chiropractors, physiotherapists and an assortment of other professionals together offer about thirty-six
therapeutic modalities for the treatment of LBP. In this study we focused principally on the effectiveness and cost-
effectiveness of chiropractic and medical management of LBP.
F1. On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by
chiropractors is shown to be more effective than alternative treatments for LBP. Many medical therapies are of
questionable validity or are clearly inadequate.
F2. There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation
is unsafe in the treatment of low-back pain. Some medical treatments are equally safe, but others are unsafe and
generate iatrogenic complications for LBP patients. Our reading of the literature suggests that chiropractic
manipulation is safer than medical management of low-back pain.
F3. While it is prudent to call for even further clinical evidence of the effectiveness and efficacy of chiropractic
management of LBP, what the literature revealed to us is the much greater need for clinical evidence of the validity
EXECUTIVE SUMMARY PAGE 2
of medical management of LBP. Indeed, several existing medical therapies of LBP are generally contraindicated
on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal
manipulations are less safe and less effective when performed by non-chiropractic professionals.
F4. There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more
cost-effective than medical management. We reviewed numerous studies that range from very persuasive to
convincing in support of this conclusion. The lack of any convincing argument or evidence to the contrary must
be noted and is significant to us in forming our conclusions and recommendations. The evidence includes studies
showing lower chiropractic costs for the same diagnosis and episodic need for care.
F5. There would be highly significant cost savings if more management of LBP was transferred from physicians to
chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions
annually. The literature clearly and consistently shows that the major savings from chiropractic management
come from fewer and lower costs of auxiliary services, much fewer hospitalizations, and a highly significant
reduction in chronic problems, as well as in levels and duration of disability. Workers' compensation studies
report that injured workers with the same specific diagnosis of LBP returned to work much sooner when treated
by chiropractors than by physicians. This leads to very significant reductions in direct and indirect costs.
F6. There is good empirical evidence that patients are very satisfied with chiropractic management of LBP and
considerably less satisfied with physician management. Patient satisfaction is an important health outcome
indicator and adds further weight to the clinical and health economic results favouring chiropractic management
F7. Despite official medical disapproval and economic disincentive to patients (higher private out-of-pocket cost),
the use of chiropractic has grown steadily over the years. Chiropractors are now accepted as a legitimate healing
profession by the public and an increasing number of physicians.
F8. In our view, the constellation of the evidence of:
(a) the effectiveness and cost-effectiveness of chiropractic management of low-back pain.
(b) the untested, questionable or harmful nature of many current medical therapies.
(c) the economic efficiency of chiropractic care for low-back pain compared with medical care.
(d) the safety of chiropractic care.
(e) the higher satisfaction levels expressed by patients of chiropractors, together offers an overwhelming case
in favour of much greater use of chiropractic services in the management of low-back pain.
F9. The government will have to instigate and monitor the reform called for by our overall conclusions, and take
appropriate steps to see that the savings are captured. The greater use of chiropractic services in the health care
delivery system will not occur by itself, by accommodation between the professions, or by actions on the part of
the Workers' Compensation Board and the private sector generally.
Our recommendations for reform include the following:
R1. Current policy discourages the utilization of chiropractic services for the management of LBP. There should be
a shift in policy to encourage and prefer chiropractic services for most patients with LBP.
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R2. Chiropractic services should be fully insured under the Ontario Health Insurance Plan, removing the economic
disincentive for patients and referring health providers. This one step will bring a shift from medical to
chiropractic management that can be expected to lead to very significant savings in health care expenditure, and
even larger savings if a more comprehensive view of the economic costs of low-back pain is taken.
R3. Chiropractic services should be fully integrated into the health care system. Because of the high incidence and
cost of LBP, hospitals, managed health care groups (community health centres, comprehensive health
organizations, and health service organizations) and long-term care facilities should employ chiropractors on a
full-time and/or part-time basis. Additionally such organizations should be encouraged to refer patients to
R4. Chiropractors should be employed by tertiary hospitals in Ontario. Hospitals already employ chiropractic in the
United States with good effect. Similar recommendations have been made recently by government inquiries in
Australia and Sweden, and following government funded research in the U.K. and other countries. Unnecessary
or failed surgery is not only costly but also represents low quality care. The opportunity for consultation, second
opinion and wider treatment options are significant advantages we foresee from this initiative which has been
employed with success in a clinical research setting at the University Hospital, Saskatoon.
R5. Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who
have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice
and patients' needs.
R6. Chiropractors should have access to all pertinent patient records and tests from hospitals, physicians, and other
health care professionals upon the consent of their patients. Access should be given upon the request of
chiropractors or their patients.
R7. Since low-back pain is of such significant concern to worker's compensation, chiropractors should be engaged
at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with back
injuries. This should be on an interdisciplinary basis with other professional, technical and managerial staff so
that there is early development of more constructive relationships between chiropractors, physicians,
physiotherapists and Board staff and consultants. A very good case can be made for making chiropractors the
gatekeepers for management of low-back pain in the workers' compensation system in Ontario.
R8. The government should make the requisite research funds and resources available for further clinical evaluation
of chiropractic management of LBP, and for further socio-economic and policy research concerning the
management of LBP generally. Such research should include surveys to obtain a better understanding of patients'
choices, attitudes and knowledge of treatments with respect to LBP. The objective of these surveys should be
better information for health policy, programme planning and consumer education purposes.
R9. Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate
public funding. Chiropractic is the only regulated health profession in Ontario without public funding for
education at present, and it works against the best interests of the health care system for chiropractors to be
educated in relative isolation from other health science students.
R10. Finally, the government should take all reasonable steps to actively encourage cooperation between providers,
particularly the chiropractic, medical and physiotherapy professions. Lack of cooperation has been a major factor
in the current inefficient management of LBP. Better cooperation is important if the government is to capture the
large potential savings in question and, it should be noted, is desired by an increasing number of individuals
within each of the professions.