Low back pain is a worldwide epidemic in human suffering and as a result, an economic burden to federal, state, public and self-insured risk-takers who insure the injured. In 2009, Russo, Weir and Elixhauser1 reported that 3.9 of every 1,000 people ages 55-64 years require a hospital stay for low back pain - the number-eight reason for hospital stays, closely behind cardiac conditions and degenerative arthritis.While low back pain has been well-chronicled, recurring low back pain and the necessity for chronic care is now beginning to realize results that necessitate the proper approach to mitigate its frequency, duration and economic impact.
A significant component of low back pain is its recurrence after initial care has been rendered, as well as the complications that can ensue. Wasiak, Kim and Pransky2 reported in 2006: "Recent studies suggest that acute low back pain evolves into a chronic or recurrent condition more often than previously suspected." They also stated that 40 percent of individuals with recurring low back pain sought additional care when the pain recurred, and 42.9 percent of those had continued care and work disability lasting more than 201 days, underscoring the significance of the problem.
According to Dagenais, Caro and Haldeman in 2007,3 "The economic burden of a disease is the sum of all costs associated with that condition which would not otherwise be incurred if that disease did not exist. Given the many categories of costs that must be considered, it can be challenging to fully estimate the economic burden of an illness as data are often unavailable. The term 'cost' in health economics refers to the value of the consequences of using a particular good or service rather than its price. ... Despite this example, it should be made clear that estimating the economic burden of a disease is not simply a matter of tabulating the amount reimbursed for all clinician services related to a particular diagnosis. The total cost of illness - or economic burden - has three components: (1) direct (medical and nonmedical) costs; (2) indirect costs; and (3) intangible costs."
Indirect and intangible costs are significant burdens, but let's focus solely on direct costs. When considering direct costs for work-related claims, studies indicate that non-work-related indemnity plans should be included for work-related low back injuries. Lipscomb, et al.,4 reported in 2009: "The private health insurance payment rates for workers with one work-related injury were 40% higher than for those with no history of work injury." The reasons are simple: Indemnity carriers are victims of many workers' compensation carrier tactics, as reported by Griffin (2007),5 to deny, delay and defend. Patients need care and will access any system at their disposal so they can get necessary care and return to a normal, pain-free lifestyle, leaving the indemnity carriers to absorb those financial costs. Although this is a significant factor, it is difficult to assign numbers and amounts that are directly tied to work-related injuries, although those statistics undoubtedly tally in the billions.
Utilizing the New York State Workers' Compensation Board's 2009 Joint Report to the Governor as a reference,6 in 2004 the total number of claims in New York was 143,667. Of those claims, 19.3 percent were low-back-related. The total costs for treating low back was $579,675,476.96 ($5.79 million), calculated for inflation to 2011 (Tom's Inflation Calculator, 1997-2011). This equates to $29.88 per resident to treat work-related low back pain; nationally, this equates to $9,262,855,559 ($9.26 billion) based upon U.S. Census statistics.7
Cifuentes, Willets and Wasiak (2011)8 compared treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study, which concluded that chiropractic care during the health maintenance care period resulted in:
- 16 percent decrease in disability duration of first episode compared to physical therapy
- 240 percent decrease in disability duration of first episode compared to medical physician care
- 6.6 percent decrease in opioid (narcotic) use during maintenance care compared to physical therapy care
- 17.2 percent decrease in opioid (narcotic) use during maintenance care compared to medical physician care
- 32 percent decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
- 21 percent decrease in average weekly cost of medical expenses during disability episode compared to medical physician care
The study also concluded that chiropractic care during the disability episode resulted in:
- 24 percent decrease in disability duration of first episode compared to physical therapy
- 250 percent decrease in disability duration of first episode compared to medical physician care
- 5.9 percent decrease in opioid (narcotic) use during maintenance care compared to physical therapy care
- 30.3 percent decrease in opioid (narcotic) use during maintenance care compared to medical physician care
- 19 percent decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
- 43 percent decrease in average weekly cost of medical expenses during disability episode compared to medical physician care
Based upon the NYSWCB Joint Report to the Governor6 and the statistics rendered by Cifuentes, et al. (2011),8 the savings with chiropractic care when utilized instead of medicine and physical therapy ranges from $1,759,942,556 ($1.76 billion) compared to physical therapy to $3,983,027,890 ($3.98 billion) compared to medicine. Understanding that most medical physicians utilize physical therapy as a primary tool for back-related pain, we will average the savings to $2,871,485,223 ($2.87 billion) by utilizing chiropractic care.
In their study, Cifuentes, et al., started by proposing, "Given chiropractors are proponents of health maintenance care ... patients with work-related low back pain who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used." They concluded by stating, "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."8
- Russo A, Wier LM, Elixhauser A. Hospital Utilization Among Near-Elderly Adults, Ages 55 to 64 Years, 2007. Statistical Brief #79, Agency for Healthcare Research and Quality, September 2009.
- Wasiak R, Kim J, Pransky G. Work disability and costs caused by recurrence of low back pain: longer and more costly than in first episodes. Spine, 2006;31(2):219-225.
- Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine,2008;8(1):8-20.
- Lipscomb H, Dement J, Silverstein B, Cameron W, Glazner J. Who is paying the bills? Health care costs for musculoskeletal back disorders, Washington State Union Carpenters, 1989-2003. Journal of Occupational and Environmental Medicine, 2009;51(10):1185-1192.
- Griffin D. "Insurance Companies Fight Paying Billions in Claims." Anderson Cooper 360* (blog), Feb. 7, 2007.
- New York State Workers' Compensation Board. Joint Report to the Governor, March 2009. Superintendent of insurance and chair, Workers' Compensation Board, summarizing and benchmarking workers' compensation data and examining progress on prior recommendations for improvement in data collection.
- U.S. Census Bureau. U.S. POPClock Projection. Dec. 22, 2010.
- Cifuentes M, Willets J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 2011;53(4):396-404.
Dr. Mark Studin is an adjunct associate professor at the University of Bridgeport School for Chiropractic, teaching advanced imaging and triaging chronic and acute patients; and an adjunct postdoctoral professor at Cleveland University-Kansas City College of Chiropractic. He is also a clinical instructor for the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. Dr. Studin consults for doctors of chiropractic, medical primary care providers and specialists, and teaching hospitals nationally. He can be reached at