Using Research to Defend Chiropractic: Medicare Edition
Written by Editor   
Wednesday, September 03, 2014 02:47 PM

The best way for doctors of chiropractic (DCs) to respond is with facts, context and research.  When responding to attacks on the value of chiropractic care for Medicare patients and older adults specifically, DCs should be particularly conversant on two recent randomized trials: one on chronic low-back pain by Maria Hondras, DC, PhD, and colleagues and the other on chronic neck pain by a team led by Michele Maiers, DC, MPH. These were the first, and remain the only, randomized clinical trials on chiropractic care for older people. In light of the demographic bulge of the baby boomer generation now entering the Medicare rolls, these studies should be seen as an essential part of our outreach toolkit.

The first-ever randomized clinical trial of chiropractic care for geriatric patients was published in 2009 in the Journal of Manipulative and Physiological Therapeutics (JMPT) by a team of investigators at Palmer College of Chiropractic led by veteran chiropractic researcher Maria Hondras. Artfully crafted, this trial compared results of two biomechanically distinct chiropractic methods and also included a group that was treated with minimal conservative medical care. 

The primary outcome variable was low-backrelated disability assessed with the 24-item Roland Morris Disability questionnaire at 3, 6, 12 and 24 weeks. The results were quite favorable to chiropractic, with people receiving the two different forms of chiropractic manual manipulation achieving the same levels of improvement, which exceeded the progress achieved by the group receiving medical care.

Describing this important study five years after its 2009 publication, Dr. Hondras, now a PhD fellow at the University of Southern Denmark’s Institute of Sports Science and Clinical Biomechanics, says, “As with most randomized controlled trials examining chiropractic interventions, we found small advantages of our manual therapy treatments over minimal conservative medical care in the areas of pain and functional status. These changes may have great value for individual patients who are 55 and older.” She also points out that there were no serious side effects from either low- or high-velocity spinal manipulation, “and in this sense older adults may be more confident about choosing chiropractic as an effective and safe option for their back pain. Given that participants in our trial had relatively uncomplicated low back pain, it will be important to replicate similar work in older adults with co-morbid conditions.”

The first randomized clinical trial on chiropractic treatment of chronic mechanical neck pain in seniors was published by Maiers et al. in Spine Journal in 2013. This study was funded by the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services. Unlike the Hondras low-back pain study, Maiers’ neck pain trial involved a single method of spinal manipulation, with the researchers assessing the relative effectiveness of manipulation and supervised rehabilitative exercise, both in combination with, and compared to home exercise alone for neck pain in 241 individuals age 65 years or older.

Patient self-report outcomes were collected at baseline and 4, 12, 26 and 52 weeks after randomization. The primary outcome was pain, measured by an 11-box numerical rating scale. Secondary outcomes included disability (Neck Disability Index), general health status (Medical Outcomes Study Short Form-36), satisfaction (7-point scale), improvement (9-point scale) and medication use (days per week).

After 12 weeks of treatment, the manipulationplus- home-exercise group demonstrated a 10 percent greater decrease in pain compared with the home-exercise-only group, and five percent change over supervised-plus-home exercise. Analysis incorporating primary and secondary patient-rated outcomes showed that the manipulation plus home exercise group was superior to the home-exercise-alone group in both the short and long term.

The chiropractic best practices document developed in accordance with these methods was published in theJMPT in 2010, and its conclusions (with the references on which they are based) can be accessed on the website of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), a broad-based organization whose mission includes generating, updating and providing web access to evidence-based clinical guidelines and reports through the CCGPP Rapid Response Resource Center (R3C). It is important to note that the recommendations on geriatric care by chiropractors reflect an understanding that chiropractic practice involves far more than delivery of spinal adjustments.