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Academy of Chiropractic’s

MD Relationship Program

#11 Clinical Information, Diagnosing and MRI

Research Consultation 

From: William J Owens Jr DC DAAMLP

 

A recent article by Fritz et al (2016) stated, “Research increasingly points to the importance of early care decisions and guideline adherence in the prognosis of patients with LBP who seek care. For example, ordering a magnetic resonance imaging (MRI) or prescribing opioids within the first weeks is associated with increased risk for persistent symptoms, work disability and high costs.” [pg 247] This is according to the authors.  It should be noted that this paper is based on data obtained from a managed care plan in Utah and was for lower back pain only. This is the first type of paper on this topic so it stands to reason that they looked at lower back pain.

The authors reported, “The purposes of this study were (1) describe the entry providers chosen by individuals with private health insurance for a new LBP consultation, (2) examine differences in patient characteristics based on entry setting and (3) examine associations between entry setting and duration of episode of care, subsequent health care costs and risk for utilization of specific procedures including radiographs, advanced imaging, injections, emergency department or spine surgeon visits, or surgery for LBP.” [pg 248]

When the authors looked at the provider that was accessed by the lower back pain, they reported, “Based on the procedure code and provider associated with the entry visit, we categorized the entry setting as (1) primary care (family medicine, internal medicine, obstetrics/gynaecology), (2) physiatry, (3) chiropractic, (4) physical therapy, (5) spine surgeon (orthopedic or neurosurgeon), (6) emergency department or (7) other doctor specialty (e.g. rheumatologist, neurologist, etc.). [pg 248]

The number of patients in the study was significant, with the paper stating, “A total of 862 individuals had a new LBP consultation during the study dates, and 747 met all inclusion criteria (Figure 1). Entry visit setting was most commonly primary care (n = 409, 54.8%) followed by chiropractic (n = 207, 27.7%), physiatry (n = 83, 11.1%) and physical therapy (n = 48, 6.4%).” [pg 249]  I found this very interesting, specifically that chiropractic care was sought out by 27% of those patients with lower back pain which was only second to primary care physicians. Thinking about chiropractic treating 27% of those with lower back pain is different than saying we treat 12% of the US population.  I believe this to be more accurate since we are getting a % of those WITH PAIN.  I was surprised by how low the physical therapy percentage was in this paper. 

They continue, “Relative to beginning in primary care, entry with a chiropractor or physical therapist was associated with reduced risk for imaging, injections, surgical consultation and surgery, while entry with a physiatrist increased risk for many of these outcomes and overall LBP-related health care costs.” [pg 249] It is important to realize that focusing on BOTH the anatomical and biomechanical causes of lower back pain is best way to ensure proper short and long-term care.  Anatomic treatments [injections, meds] do not reliably treat mechanical problems in the spine, remember, there is no medication for a subluxation/fixation/compensation in the spine.  Only the adjustment can fix that, provided it is accurately diagnosed.  Costs are driven up when the patient is mismanaged from the beginning. 

The authors reported, “More specifically, existing studies suggest there may be reduced exposure to expensive and invasive procedures and lower costs when a non-doctor provider [not a fan of this descriptor – should be non-physician] such as a physical therapist or chiropractor is the initial provider compared with patients beginning with a medical doctor.” [pg 250] That is because the patient is managed from a mechanical standpoint first, which is being shown to be more and more effective in eliminating unnecessary diagnostic testing and treatments. 

“A recent review found chiropractors and physical therapists are more likely to provide guideline-adherent care for LBP than primary care doctors. Non-doctor providers are unable to order MRIs or prescribe opioids in contradiction to guidelines.”  [This certainly true of narcotic medication however chiropractors are allowed under their individual scope to order radiographs and advanced imaging in the presence of neurological deficit or a non-response to initial care, this is important since the chiropractor has the training and scope of practice to be able to manage patients that have more significant diagnosis such as disc herniation].  The authors continue, “Physical therapists in the United States are unable to order radiographs.”  This is important to note since long term management of chronic spine pain will have to fall back on the medical provider, which in the case of this paper typically drives up costs.  The authors also commented, “Non-doctor providers also tend to see patients more frequently and for longer durations, providing greater opportunity for patient education. Time constraints and difficulty providing adequate education about activity are cited by primary care doctors as challenges for providing evidence-based care to patients with LBP.” [pg 250]  In the end, the chiropractor has the scope of practice and the education to not only serve as a portal of entry but has the skill set to triage those patients who have a true anatomical cause to their pain [fracture, infection, tumor].

When it comes to portal of entry for spine care, we can see that the credentialed chiropractic [advanced training in spinal biomechanics and MRI Spine Interpretation] can fulfill a significant and much needed role in the care of the spine pain patient.  This in turn takes the burden away from Primary Care Physicians and Medical Specialist to focus on what they do best, the former being management of chronic internal medicine disorders and the latter being procedures [injection or surgery] when medical necessary. 

 

 

1.Fritz, J. M., Kim, J., & Dorius, J. (2016). Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs. Journal of evaluation in clinical practice22(2), 247-252.

 

 

 

 

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