The primary aim of this study was to determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types.           

Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient’s costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD.​

  • Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer.   J Manipulative Physiol Ther 2010 (Nov); 33 (9): 640–64     Richard L. Liliedahl, MD, Michael D. Finch, PhD, David V. Axene, FSA, FCA, MAAA, Christine M. Goertz, DC, PhD 

When considering effectiveness and cost together, chiropractic physician care for low back and neck pain is highly cost effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.  Because we were unable to incorporate savings in drug spending commonly associated with US chiropractic care, our estimate of its comparative cost-effectiveness is likely to be understated.​

  • Do Chiropractic Physician Services for Treatment of Low Back and Neck Pain Improve the Value  of Health Benefit Plans?  Mercer Health and Benefits San Fransisco 2009     Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD, MPH

The results of the review showed that the reported proportion of patients who still experienced pain after 12 months was 62% on average (range 42-75%), the percentage of patients sick-listed 6 months after inclusion into the study was 16% (range 3-40%), the percentage who experienced relapses of pain was 60% (range 44-78%), and the percentage who had relapses of work absence was 33% (range 26-37%). The mean reported prevalence of LBP in cases with previous episodes was 56% (range 14-93%), which compared with 22% (range 7-39%) for those without a prior history of LBP. The risk of LBP was consistently about twice as high for those with a history of LBP.

The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.

  • Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 2003 Apr;12(2):149-65     Hestbaek L, Leboeuf-Yde C, Manniche C.  The Backcenter, Ringe Hospital, Odense University Hospital, 5950 Ringe, Denmark

OBJECTIVE:   A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The purpose of this report is to describe the implementation and results of a multidisciplinary, evidence-based, standardized process to improve clinical outcomes and reduce costs associated with treatment and diagnostic testing.

RESULTS:   The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as "excellent."​

  • A hospital-based standardized spine care pathway: report of a multidisciplinary, evidence-based process. J Manipulative Physiol Ther. 2011 Feb;34(2):98-106     Paskowski I, Schneider M, Stevans J, Ventura JM, Justice BD

Low back pain is the fifth most common reason for all physician visits in the United States. Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months, and 7.6% reported at least 1 episode of severe acute low back pain within a 1-year period.  Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998. In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year.

Many patients have self-limited episodes of acute low back pain and do not seek medical care. Among those who do seek medical care, pain, disability, and return to work typically improve rapidly in the first month. However, up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode and 1 in 5 report substantial limitations in activity. Approximately 5% of the people with back pain disability account for 75% of the costs associated with low back pain.

For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

  • Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society  Ann Intern Med. 2007;147:478-491     Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel

The objective of this report is to describe and assess the evidence from randomized controlled trials (RCTs) and other prospective, comparative clinical trials (CCTs) for the efficacy and safety of behavioral and physical treatments for tension-type and cervicogenic headache. The report is limited to therapies that have been studied specifically among populations of patients with tension-type or cervicogenic headache. As a result, some treatments routinely used by health care providers to treat these types of headache may not be represented

Cervical Spinal manipulation was associated with improvement in headache outcomes in two trials involving patients with neck pain and/or neck dysfunction and headache. Manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache when compared with an attention-placebo control. Furthermore, when compared to soft-tissue therapies (massage), a course of manipulation treatments resulted in sustained improvement in headache frequency and severity. 

  • Evidence Report:  Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache
    Duke University Evidence-based Practice Center for Clinical Health Policy Research. 2001     
    McCrory DC, Penzien DB, Hasselblad V, Gray RN.

Back and neck pain are important health problems with serious societal and economic implications. Conventional treatments have been shown to have limited benefit in improving patient outcomes. Complementary and Alternative Medicine (CAM) therapies offer additional options in the management of low back and neck pain. Many trials evaluating CAM therapies have poor quality and inconsistent results

This systematic review was undertaken to evaluate which complementary and alternative medicine (CAM) therapies are being used for persons with back pain in the United States.

"For both low back and neck pain, manipulation was significantly better than placebo or no treatment in reducing pain immediately or short-term after the end of treatment. Manipulation was also better than acupuncture in improving pain and function in chronic nonspecific low back pain."

  • Complementary and Alternative Medicine in Back Pain Utilization  2010 Oct. Report No.:10(11)-E007
    University of Ottawa Evidence-based Practice CenterAgency for Healthcare Research and Quality (US)

Evidence-based clinical practice guidelines for the management of patients with acute mechanical low back pain have been defined on an international scale. Multicenter clinical trials have demonstrated that most acute mechanical low back pain patients do not receive clinical practice guideline-based treatments. To date, the value of implementing full and exclusively clinical practice guideline based treatment remains unclear.

PURPOSE OF STUDY: To determine if full clinical practice guideline-based study care results in greater improvement in functional outcomes than family physician–directed usual care in the treatment of acute mechanical low back pain.

CONCLUSIONS: This is the first reported randomized controlled trial comparing full clinical practice guidelines –based treatment, including spinal manipulative therapy administered by chiropractors, to family physician–directed usual care in the treatment of patients with acute mechanical low back pain. Compared to family physician–directed usual care, full clinical practice guidelines -based treatment including Chiropractic Spinal Manipulative Therapy is associated with significantly greater improvement in condition-specific functioning.

  • The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.  Spine J. 2010 Dec; 10(12):1055-64.     Paul B. Bishop, DC, MD, PhD, Jeffrey A. Quon, DC, PhD, FCCSC, Charles G. Fisher, MD, MHSc, FRCSC, Marcel F.S. Dvorak, MD, FRCSC

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Research: ​ Chiropractic facts supporting effectiveness, safety, and cost savings of Chiropractic treatments.

  • Magnetic Resonance Imaging Zygapophyseal Joint Space Changes (Gapping) in Low Back Pain Patients following Spinal Manipulation and Side Posture Positioning: A Randomized Controlled Mechanisms Trial with Blinding   J Manipulative Physiol Ther. May 2013; 36(4): 203–217     Gregory D. Cramer, DC, PhD, Professor and Dean of Research, Jerrilyn Cambron, DC, MPH, PhD, Professor, Joe A Cantu, DC, Radiological Consultant, Jennifer M. Dexheimer, LMT, BS, Clinical Research Coordinator, Judith D Pocius, MS, Morphometry Technician, Douglas Gregerson, DC, Adjunct Professor, Michael Fergus, DC, Assistant Professor, Ray McKinnis, PhD, Statistical Consultant, and Thomas J Grieve, DC, MPH, Instructor

Adhesions have been previously identified in many hypomobile joints, but not in the zygapophyseal (Z) joints of the spine. The objective of this study was to determine if connective tissue Adhesions developed in lumbar Z joints after induced intervertebral hypomobility (segmental fixation).

Results: Connective tissue Adhesions were characterized and their location within Z joints described. Small and medium Adhesions were found in rats from all study groups. However, large Adhesions were found only in rats with 8, 12, or 16 weeks of experimentally induced intervertebral hypomobility. Significant differences among study groups were found for small, medium, and large Adhesions. The average number of medium and large Adhesions per joint increased with the length of experimentally induced hypomobility in rats with 8 and 16 weeks of induced hypomobility.

Conclusions: We conclude that hypomobility results in time-dependent Adhesion development within the Z joints. Such Adhesion development may have relevance to spinal manipulation, which could theoretically break up Z joint intra-articular Adhesions.​

Last Updated: 01/25/15

"Supposing is good, but finding out is better."  — Mark Twain

The purpose of this study was to quantify lumbar zygapophyseal (Z) joint space separation (gapping) in low back pain (LBP) subjects after spinal manipulative therapy (SMT) or side-posture positioning (SPP).


In this study of acute LBP subjects, side-posture positioning subjects showed the greatest Z joint gapping at the baseline MRI appointment. After two weeks of standard chiropractic treatment, SMT followed by side-posture positioning, resulted in the greatest amount of Z joint gapping, followed by side-posture positioning alone; these results are consistent with those of previous studies on healthy subjects. The side-posture position appeared to have additive therapeutic benefit to SMT, with acute LBP subjects receiving SMT and remaining in side-posture experiencing the greatest reduction of pain, independent of Z joint gapping, at the first appointment and the greatest amount of Z joint gapping after 2 weeks of care.​​​

  • Zygapophyseal joint adhesions after induced hypomobility.  J Manipulative Physiol Ther. 2010 Sep;33(7):508-18
    Cramer GD1, Henderson CN, Little JW, Daley C, Grieve TJ.

The practice of Chiropractic has remained relatively unchanged for over 100 years, and even with new technologies in practice, the manual manipulation of joints remains the defining characteristic of Chiropractic.

The enduringness of Chiropractic alone should speak to its efficacy, yet many people are still reluctant to experience Chiropractic, or other forms of Alternative Medicine for that matter.  It is estimated that only 8 – 10 % of the population utilizes Chiropractic treatments  as a form of healthcare. 

Part of the issue with the acceptance of Chiropractic care into mainstream medical care has been the lack of research.  Thankfully the research is finally being published and Chiropractic is beginning to be integrated with standard medical practices.  Chiropractors are now on staff at many VA hospitals in the US and based on preliminary reports more will be added in the near future.  Integration of Chiropractic into the standard medical model is something that I am personally passionate about as I believe that collaborative care between MDs and DCs will provide better results for patients and be more cost effective for healthcare.

Here are a few of the reports and research articles that attest to the efficacy and cost effectiveness of chiropractic treatments.