A study published in the April 2011 issue of the Journal of Occupational and Environmental Medicine suggests that when it comes to work-related low back pain, the risk of disability recurrence is lower for patients treated primarily ("only or mostly") by a doctor of chiropractic than patients treated only/mostly by a physical therapist or a physician.The study defined recurrence in terms of disability following return to work, while patients were under "health maintenance care" by their provider. From a cost perspective, the study also found that average costs of care per disability episode and during the "health maintenance phase" following return to work were higher for patients with recurrent episodes of LBP compared to those with no such recurrence.
The study, "Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence," by Manuel Cifuentes (a medical doctor), et al., defined primary provider type ("only or mostly") as "the provider for which the patient sought care for at least 50 percent of visits."Study participants were tracked from their initial disability episode through their return to work (the "health maintenance care period"), with maintenance care ensuing "after the initial disability episode had ended and the [patient] had returned to work for more than 14 days."
The primary outcome variable, time to disability recurrence, was defined as "the number of days between the first day of returning to work for at least 15 consecutive days after the initial disability episode until the day before recurrence of disability." Patients with a recurrence of their condition were classified as such if they had received at least 15 consecutive days of temporary total disability payments following the health maintenance care period.
A large insurance company representing an estimated 10 percent of U.S. workers' compensation cases provided data for the study. Low back pain cases (11,420 new cases of nonspecific LBP) were identified via the company's administrative records and all claimants were tracked from the initial date of injury until one year following the first episode of disability. Claimants who had filed a workers' compensation claim for nonspecific LBP in the prior year were identified and excluded, allowing for evaluation of new-onset cases of nonspecific LBP only (894 cases; average age: 41 years).
Average job tenure for study participants was two years, with transportation and material moving, production, office and administrative support, and building and ground cleaning the most frequent jobs performed.
Likelihood of Recurrence
- "Provider type during the health maintenance care period was significantly associated with recurrent disability ... with the only or mostly physical therapy group having the highest proportion of recurrent disability (16.9%) and the only or mostly chiropractor and the no health maintenance care groups having the lowest proportion of recurrent disability (6.5% and 5.5%, respectively)." More than 12 percent (12.5%) of patients receiving care from a physician experienced recurrent disability.
- "Provider type during disability episode was associated with the hazard of disability recurrence after returning to work. Compared with the only or mostly chiropractor (referent), the groups of only or mostly physical therapy and only or mostly physician had significantly higher HRs (2.0 and 2.7, respectively)."
Among the study population, 11 percent experienced recurrent disability attributable to work-related LBP, with recurrence contributing to substantially higher treatment costs per disability episode ($122 higher average weekly cost) compared to patients with no recurrence of their LBP. Overall, average weekly cost during a disability episode was $565 for recurrent vs. $444 for non-recurrent. During the health maintenance care phase, cost differences were even more pronounced: $371 average weekly treatment costs for patients with a recurrence of their disability compared to only $53 for patients with no recurrence.
Better Off Without "Traditional Medical Approaches"?
- "We dare to speculate that for the purpose of preventing disability recurrence in cases of work-related LBP, the main advantage of chiropractors could be based on the dual nature of their practice. On one hand, it is the do-nothing approach: by visiting only or mostly a chiropractor or becoming a chiropractor loyalist [defined in the study as the patient's preferred type of provider, independent of the provider type from whom the patient received most or all care during the study period], the patients do not receive other traditional medical approaches. ... There is a growing evidence that health-care-as-usual does not necessarily improve health outcomes in nonspecific LBP."
- "This hypothesis is supported by our finding that ... no health maintenance care is generally as good as chiropractor care. Therefore, not as a conclusion but a hypothesis, chiropractors might be preventing some of their patients from receiving procedures of unproven cost utility value or dubious efficacy."
- [T]he only or mostly chiropractor group during the disability episode and health maintenance care periods and 'chiropractor loyalists' during both periods combined had fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups."
"After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type. Even without an improvement in days until recurrent disability, our findings seem to support the use of chiropractic services, as chiropractor services generally cost less than services from other providers. If a lower rate of disability recurrence in work-related LBP cases for chiropractors [holds true], it is important to identify the mechanism of action."
Chiropractic Maintenance Care
The Cifuentes, et al., findings come on the heels of the Senna, et al., study in Spine that found chronic LBP patients who received nine months of maintenance spinal manipulative therapy following one month of treatment reported significant improvement in pain and disability. Patients who received only the initial month of treatment reported diminishing improvement over time, with pain and disability scores returning essentially to pretreatment levels after 10 months. (For more information, read "More Better Than Less for Chronic LBP" in the May 6 issue of DC.)
Access the complete workers' comp study in the print issue of JOEM or online: Cifuentes M, Willetts J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. JOEM, April 2011;53(4):396-404.