Few health care interventions have been assessed as extensively as chiropractic in terms of both safety and effectiveness; and few others have been as thoroughly researched.
At least six formal government inquiries into chiropractic worldwide over the last 25 years have concluded that contemporary chiropractic is safe, beneficial and cost effective.
J. David Cassidy, DC, PhD, DrMedSc, Eleanor Boyle, PhD, Pierre Cote, DC, PhD, Helen He, MD, PhD, Sheilah Hogg-Johnson, PhD, Frank L. Silver, MD, FRCPC, and Susan J. Bondy, PhD. (2008) "Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-based Case-control and Case-crossover Study", SPINE, Volume 33, Number 4S.
This study investigated associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and contrasted this with primary care physician (medical doctor) visits and VBA stroke. Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and medical doctors were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls.
Conclusion: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with both chiropractic and medical doctor visits is likely due to patients with headaches and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to medical care.
Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey
Haymo W. Thiel, DC, PhD, Jennifer E. Bolton, Phd, Sharon Docherty, PhD, and Jane C. Portlock, PhD. (2007) "Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey". SPINE, Volume 32, Number 21, pp 2375-2378.
Treatment outcomes from 19,722 patients were studied to estimate the risk of serious and relatively minor adverse events following chiropractic manipulation of the cervical spine by a sample of U.K. chiropractors. Desired outcome was a better understanding of the risk of a serious adverse event following chiropractic manipulation of the cervical spine, which was largely unknown prior to study.
Data obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations concluded there were no reports of serious adverse events. Although minor side effects (fainting/dizziness/light-headedness) following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.
"United Kingdom Back Pain Exercise and Manipulation (BEAM) Randomized Trial: Cost-Effectiveness of Physical Treatments for Back Pain in Primary Care", British Medical Journal, November 2004 and American Medical Association's Archives of Internal Medicine December 2004, 329, 1377.
This randomized trial sought to estimate the effect of adding exercise, spinal manipulation delivered in NHS or private premises, and manipulation followed by exercise to "best care" in general practice for patients consulting with back pain. The trial compared a class based general exercise program and a spinal manipulation package with "best care" in general practice based on "active management."
At three months, exercise improved mean disability questionnaire scores by 1.4 more than "best care". At the same mark, manipulation saw an additional improvement of 1.6, and manipulation followed by exercise showed an additional improvement of 1.9. No significant differences in outcome occurred between NHS premises and private premises.
Mosley, C.C., Hana, G.C., Arnold, R.M. (1996) "Cost-Effectiveness of Chiropractic in a Managed Care Setting", The American Journal of Managed Care, Vol. 2, pp. 280-282.
This study retrospectively evaluated the cost of health care for back and neck pain (using ICD-9 codes) for members of a health maintenance organization who sought chiropractic care in 1994-95. In addition, differences between the groups in surgical rates, the use of diagnostic imaging and patient satisfaction were compared. The cost of health care for back and neck pain was substantially lower for chiropractic patients ($539 versus $774).
The authors concluded that properly managed chiropractic care can yield outcomes, in terms of surgical requirements and patient satisfaction, that are equal to those of non-chiropractic care, at a substantially lower cost per patient.
Stano, M., Smith, M. (1996) "Chiropractic and Medical Costs of Low Back Pain", Medical Care, Vol. 34(3), pp. 191-204.
This study compared health insurance payments and utilization for episodes of care for common low back conditions treated by chiropractic and medical providers, using two years of insurance claim data. The mean total payments were lower for chiropractic care ($518) versus medical care ($1,020), as were the mean total outpatient costs ($477 versus $598).
The authors concluded the lower costs for episodes in which chiropractors serve as initial contact providers along with favorable satisfaction and quality indicators suggests chiropractic deserves careful consideration in gatekeeping strategies adopted by employers and third-party payers to control health care spending.
Manga, P., Angus, D., Papadopoulos, C., Swan, W. (1993) The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain, Kenilworth Publishing, Ottawa.
In 1993, the Ontario Ministry of Health commissioned and funded a study to examine the effectiveness and cost-effectiveness of chiropractic management of low back pain. The report concluded that there is an overwhelming body of evidence indicating that chiropractic management of low back pain is the most cost-effective, and that there would be highly significant cost savings if more management of low back pain were transferred to chiropractors.
This report also recommended that there should be a shift in policy to encourage chiropractic services for most patients with low and that chiropractic services be fully insured under the Ontario Health Insurance Plan.
Ebrall, P.S. (1992) "Mechanical Low Back Pain: A Comparison of Medical and Chiropractic Management within the Victorian WorkCare Scheme", Chiropractic Journal of Australia, Vol. 22(2), pp. 47-53.
This was a retrospective study of all work-related low back pain claimants within a twelve-month period in Victoria, Australia, drawing on the database of the Victorian Accident Compensation Commission, and comparing costs for outcomes between chiropractic and medical care. The study found that:
- 1. there was a significantly lower number of claimants requiring compensation days when chiropractic management was chosen;
- 2. there were fewer compensation days taken by claimants who receive chiropractic management;
- 3. a greater number of patients progressed to chronic status when medical management was chosen; and
- 4. there was a greater average payment per claim with medical management ($2,308.10) versus chiropractic management ($963.47).
The investigator concluded that if the Victorian chiropractors managed up to 40 per cent of low back pain cases (substituting medical care) then the direct savings within the Victorian WorkCare scheme for the study period would have been $10 million over 7,482 claims.
Jarvis, K.B., Phillips, R.B., Morris, E.K. (1991) "Cost per Case Comparison of Medical Management for Conditions with Identical Diagnostic Codes", Journal of Occupational Medicine, Vol. 33(8), pp. 847-852.
This workers' compensation study compared chiropractic care to medical care back injury claims and concluded that for the total data set, cost for care was significantly more for medical claims and compensation costs were 10-fold less for chiropractic claims. It also found that chiropractic patients return to work ten times sooner after an injury. Total costs per case for the ICD-9 code for lumbar disc were found to be $8,175 for total medical care versus $1,065 for chiropractic care.
Shekelle, P.G., Adams, A.H., Chassin, M.R., Hurwitz, E.L., Phillips, R.B., Brook, R.H. (1991) "The Appropriateness of Spinal Manipulation for Low Back Pain. Project Overview and Literature Review", RAND, Santa Monica, California.
RAND, a prestigious research organization in the United States, released a report on the appropriateness of spinal manipulation for low back pain. On the efficacy of spinal manipulation for low back pain, although the investigators found that the literature on the subject is of uneven quality, they concluded that "support is consistent for the use of spinal manipulation as a treatment for patients with low back pain and an absence of other signs or symptoms of lower limb nerve root involvement."
Meade, T.W., Dyer, S., Browne, W., Townsend, J., Fran, A.O. (1990 & 1995) Randomized Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain, British Medical Journal.
In 1990, this widely reported randomized controlled trial conducted by the British Medical Research Council compared chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin. The investigators concluded chiropractic treatment almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management. They also related that consideration should be given to providing chiropractic coverage within the National Health System and in hospitals. BMJ, Vol. 300, pp. 1431-37
A follow-up study, published in the British Medical Journal in 1995, presented the full results and concluded that "at three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractors derive more benefit and long term satisfaction than those treated by hospitals." BMJ, Vol. 311, pp. 349-51.
