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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
August, 1993
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
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
of LBP.
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.
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.
... Governments are always interested in providing service for the lowest cost. The first government investigation of cost-effectiveness for chiropractic was a study in Canada on low-back pain in 1993; it reported positive findings [204]. However, evidence for improvement in patient outcomes from the correction of chiropractic subluxations or postural changes has never been documented in a peer-reviewed, indexed journal. ...
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Background: Chiropractic emerged in 1895 and was promoted as a viable health care substitute in direct competition with the medical profession. This was an era when there was a belief that one cause and one cure for all disease would be discovered. The chiropractic version was a theory that most diseases were caused by subluxated (slightly displaced) vertebrae interfering with "nerve vibrations" (a supernatural, vital force) and could be cured by adjusting (repositioning) vertebrae, thereby removing the interference with the body's inherent capacity to heal. DD Palmer, the originator of chiropractic, established chiropractic based on vitalistic principles. Anecdotally, the authors have observed that many chiropractors who overtly claim to be "vitalists" cannot define the term. Therefore, we sought the origins of vitalism and to examine its effects on chiropractic today. Discussion: Vitalism arose out of human curiosity around the biggest questions: Where do we come from? What is life? For some, life was derived from an unknown and unknowable vital force. For others, a vital force was a placeholder, a piece of knowledge not yet grasped but attainable. Developments in science have demonstrated there is no longer a need to invoke vitalistic entities as either explanations or hypotheses for biological phenomena. Nevertheless, vitalism remains within chiropractic. In this examination of vitalism within chiropractic we explore the history of vitalism, vitalism within chiropractic and whether a vitalistic ideology is compatible with the legal and ethical requirements for registered health care professionals such as chiropractors. Conclusion: Vitalism has had many meanings throughout the centuries of recorded history. Though only vaguely defined by chiropractors, vitalism, as a representation of supernatural force and therefore an untestable hypothesis, sits at the heart of the divisions within chiropractic and acts as an impediment to chiropractic legitimacy, cultural authority and integration into mainstream health care.
... 121 The first government investigation of the cost-effectiveness of chiropractic was a study in Canada on low back pain in 1993; it reported positive findings. 122 However, evidence for improved patient outcomes from chiropractic treatment based on the radiographic demonstration of chiropractic subluxations or postural changes has never been documented in a peer-reviewed, indexed journal. ...
Health care professions struggling for legitimacy, recognition, and market share can become disoriented to their priorities. Health care practitioners are expected to put the interests of patients first. Professional associations represent the interests of their members. So when a professional association is composed of health care practitioners, its interests may differ from those of patients, creating a conflict for members. In addition, sometimes practitioners' perspectives may be altered by indoctrination in a belief system, or misinformation, so that a practitioner could be confused about the reality of patient needs. Politicians, in attempting to find an expedient compromise, can value a "win" in the legislative arena over the effects of that legislation. These forces all figure into the events that led to the acceptance of chiropractic into the American Medicare system. Two health care systems in a political fight lost sight of their main purpose: to provide care to patients without doing harm.
... Given that chronic low back pain represents the second leading cause of disability world-wide [88] and that chiropractic appears to be a safe, effective and cost effective intervention [89] -positioning chiropractors as a mainstream partner addresses a shortfall within the health care system. Manga highlighted this almost 25 years ago [90] and today, evidence suggests that closer alliances between chiropractors and medical doctors lead to improved management, reduced chronicity and enhanced patient satisfaction. [91,92] Secondly, integration with the mainstream represents a benefit to the economy. ...
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Since its inception, the chiropractic profession has been divided along ideological fault lines. These divisions have led to a profession wide schism, which has limited mainstream acceptance, utilisation, social authority and integration. The authors explore the historical origins of this schism, taking time to consider historical context, religiosity, perpetuating factors, logical fallacies and siege mentality. Evidence is then provided for a way forward, based on the positioning of chiropractors as mainstream partners in health care.
... All have concluded that there is no clear superiority for any provider group or modality. Regarding economic evaluations, older reports [60,61] have concluded that chiropractic care is highly cost-effective because of the relatively low consultation fee and the limited use of advanced diagnostic imaging. However, more recent rigorous systematic reviews of partial economic evaluations have failed to show an economic advantage of one type of care over another [21,22]. ...
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Purpose To estimate the clinical effectiveness and to systematically review the literature of full economic evaluation of chiropractic care compared to other commonly used care approaches among adult patients with non-specific LBP. Study Design Systematic reviews of interventions and economic evaluations. Methods A comprehensive search strategy was conducted to identify 1) pragmatic randomized controlled trials (RCTs) and/or 2) full economic evaluations of chiropractic care for low back pain compared to standard care delivered by other healthcare providers. Studies published between 1990 and 4th June 2015 were considered. Primary outcomes included pain, functional status and global improvement. Study selection, critical quality appraisal and data extraction were conducted by two independent reviewers. Data from RCTs with low risk of bias were included in a meta-analysis to determine effect estimates. Cost estimates of full economic evaluations were converted to 2015 USD and results summarized using Slavin’s qualitative best-evidence synthesis. Results Six RCTs and three full economic evaluations were scientifically admissible. Five RCTs with low risk of bias compared chiropractic care to exercise therapy (n = 1), physical therapy (n = 3) and medical care (n = 1). Overall, we found similar effects for chiropractic care and the other types of care and no reports of serious adverse events. Three low to high quality full economic evaluations studies (one cost-effectiveness, one cost-minimization and one cost-benefit) compared chiropractic to medical care. Given the divergent conclusions (favours chiropractic, favours medical care, equivalent options), mixed-evidence was found for economic evaluations of chiropractic care compared to medical care. Conclusion Moderate evidence suggests that chiropractic care for LBP appears to be equally effective as physical therapy. Limited evidence suggests the same conclusion when chiropractic care is compared to exercise therapy and medical care although no firm conclusion can be reached at this time. No serious adverse events were reported for any type of care. Our review was also unable to clarify whether chiropractic or medical care is more cost-effective. Given the limited available evidence, the decision to seek or to refer patients for chiropractic care should be based on patient preference and values. Future studies are likely to have an important impact on our estimates as these were based on only a few admissible studies.
... Studies of low back pain epidemiology are quite substantial, frequency and impact of back pain are variable. It was the leading cause of disability and morbidity and the most expensive worker's compensation cost among the middle aged Canadian and North American persons (Mangaet al., 1993), it is very common that almost about half of the adult population complained from low back pain for more than a day during the year(Tissa, 2010).Also, it was estimated that prevalence of low back pain in the western countries to be 54% in men and 57% in women (Gourmelenet al., 2007). Workers in each occupation exposes to variable and unique conditions, stresses and activities. ...
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Objective: To study the prevalence of low back pain and the likelihood of association of low back pain development with specific working conditions and work related emotional factors. Methods: Participants were 256 employers, their mean age was 40.8 ±7.72(68% males, 32% females).A self-reported Nordic Musculoskeletal Questionnaire was used to collect participant's demographic and occupational data, history and characteristics of low back pain before and after their current work. Pearson's Chi square correlation and binary logistic regression analysis were used. Results:The prevalence of low back pain was 53.5% among the respondents. Statistically significant correlation of low back pain and ages, number of working hours/day, work duration and work related emotional exhaustion (p-value <0.05) was recorded. Ages (OR 1.336, 95% CI 1.284-1.690), number of working hours/day (OR 2.474,95% CI 1.605-3.814), and work duration (OR 1.592, 95%CI 1.413-1.794)are risk factors of low back pain.
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Objective: To study the prevalence of low back pain and the likelihood of association of low back pain development with specific working conditions and work related emotional factors. Methods: Participants were 256 employers, their mean age was 40.8 ±7.72(68% males, 32% females).A self-reported Nordic Musculoskeletal Questionnaire was used to collect participant's demographic and occupational data, history and characteristics of low back pain before and after their current work. Pearson's Chi square correlation and binary logistic regression analysis were used. Results:The prevalence of low back pain was 53.5% among the respondents. Statistically significant correlation of low back pain and ages, number of working hours/day, work duration and work related emotional exhaustion (p-value <0.05) was recorded. Ages (OR 1.336, 95% CI 1.284-1.690), number of working hours/day (OR 2.474,95% CI 1.605-3.814), and work duration (OR 1.592, 95%CI 1.413-1.794)are risk factors of low back pain.
Objective: The purpose of this study was to assess nurse practitioner (NP) and physician assistant (PA) students' views of chiropractic. As the role of these providers progresses in primary care settings, providers' views and knowledge of chiropractic will impact interprofessional collaboration and patient outcomes. Understanding how NP and PA students perceive chiropractic may be beneficial in building integrative health care systems. Methods: This descriptive quantitative pilot study utilized a 56-item survey to examine attitudes, knowledge, and perspectives of NP and PA students in their 2nd year of graduate studies. Frequencies and binomial and multinomial logistic regression models were used to examine responses to survey totals. Results: Ninety-two (97%) students completed the survey. There were conflicting results as to whether participants viewed chiropractic as mainstream or alternative. The majority of participants indicated lack of awareness regarding current scientific evidence for chiropractic and indicated a positive interest in learning more about the profession. Students who reported prior experience with chiropractic had higher attitude-positive responses compared to those without experience. Participants were found to have substantial knowledge deficits in relation to chiropractic treatments and scope of practice. Conclusion: The results of this study emphasize the need for increased integrative initiatives and chiropractic exposure in NP and PA education to enhance future interprofessional collaboration in health care.
Objectives: To retrospectively summarise chiropractic findings in dogs presented in a veterinary practice with urinary incontinence and urinary retention over a 6-year period, and compare these to non-urinary patients presented during the same time period. Methods: Twenty-two cases were included in the study. They all first underwent a standard clinical examination to rule out or treat other possible causes of their urinary problems. They then underwent chiropractic examination and hypomobility findings were recorded using Gonstead listings. Odds ratios (ORs) were calculated for the occurrence of chiropractic findings in urinary versus non-urinary patients for each vertebra in the lumbar, sacral and ilial regions. Results: All patients had chiropractic findings in the lumbar region that differed from non-urinary patients. The urinary patients were significantly more likely to have chiropractic findings in L3 (OR=4 · 81; 95%CI: 2 · 02 to 11 · 44; P = 0 · 0004), L4 (OR=6 · 85; 95%CI: 2 · 63 to 17 · 84; P = 0 · 0001) and L5 (OR=3 · 98; 95%CI: 1 · 64 to 9 · 69; P = 0 · 0023). In addition, urinary patients were significantly less likely to have chiropractic findings associated with the ilium (OR=0 · 26; 95%CI: 0 · 11 to 0 · 66; P = 0 · 0043). Clinical significance: This is the first report of an association between chiropractic findings in the lumbar vertebrae and urinary incontinence and retention in dogs.
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