Evaluating the Importance of Who is Delivering Care for Low Back Pain

Welcome back to Spine IQ’s BackBlog! This week, we would like to discuss findings summarized in a recent briefing from the Center for Health Workforce Studies at the University of Washington titled “Opioid prescriptions, radiography, and costs for self-limited ‘one-and-done’ lower back pain visits in a commercially insured population.”1 There is a lot of interest in healthcare right now, not only about what treatments are being delivered but who is delivering treatment for low back pain. This author group sought to address that question by analyzing a large dataset of commercially insured patients. We hope you find this research as interesting as we did!

Objective and Methods

Low back pain is the leading cause of disability and poses a large economic burden on the healthcare system.2 The incidence of low back pain is high with about 30% of people expected to suffer an episode of low back pain in a year.4 In order to mitigate public health crisis, researchers and health systems are trying to identify the most effective and cost-efficient care pathways for patients. The goal is to discover what treatments and providers are able to best improve outcomes while decreasing healthcare waste and overuse.3 About 50% of people that suffer an episode of low back pain seek healthcare, some of whom will only have a single encounter with a clinician. Researchers focused on this population, using a large insurance claims database to measure opioid prescription rates, imaging rates, and costs of care.

Opioid prescriptions were divided into 2 groups: 1) early opioid use that was prescribed and filled within 30 days of the healthcare session or 2) long-term opioid use, which included patients that filled prescriptions for 120 days or more within one year or filled prescriptions for 90 days and had ten or more refills in one year. Imaging included x-ray, MRI, or CT scans within one year of the healthcare encounter. Costs were divided into 2 outcomes: 1) total costs and 2) out-of-pocket costs paid by patients.

Results

A total of 189,205 unique “one-and-done” healthcare encounters were included in the study. Providers inlcuded family/internal medicine physicians (55%), chiropractors (21.7%), emergency medicine physicians (8.3%), orthopedic physicians (6.0%), physical medicine physicians (3.6%), registered nurses (3.4%), physical therapists (1.4%), and acupuncturists (0.6%).

Early opioid was most common in patients seeking care from physical medicine physicians (8.0%), emergency medicine (7.6%), family/internal medicine physicians (6.7%), registered nurses (5.4%), and orthopedic physicians (4.8%). Only 0.6% and 0.3% of patients seeing physical therapists or chiropractors received early opioid prescriptions. Since chiropractors and physical therapists cannot prescribe, it is likely that these prescriptions were filled by another healthcare visit not seen in this dataset. Long term opioid prescription was rare for all patients in this cohort.

Plain-film imaging was most in patients seeking care from orthopedic physicians (41.2%) followed by physical medicine physicians (13.7%), emergency medicine physicians (8.9%), chiropractors (7.9%), registered nurses (6.8%), family/internal medicine physicians (6.0%), and physical therapists (0.6%). MRI or CT scan’s were not common and most likely to be associated with care delivered by orthopedic physicians (1.8%).

The total cost of one healthcare encounter was highest for patients seeking care from emergency medicine physicians ($478) followed by physical medicine physicians ($248), registered nurses ($224), orthopedic physicians ($211), acupuncturists ($206), physical therapists ($160), and chiropractic ($91). Out-of-pocket costs were highest for patients seeking care from emergency medicine ($202) followed by acupuncturists ($110), physical medicine physicians ($103), registered nurses ($90), physical therapists ($90), family/internal medicine physicians ($61), and chiropractic ($57).

Conclusion

This data has a lot of very interesting findings for the conservative spine clinician. First, it is important to note that chiropractic was the healthcare profession that delivered the second highest amount of healthcare encounters. This demonstrates that patients with low back pain commonly seek treatment from chiropractors. Second, there is clear evidence that patients seeking care from conservative spine clinicians receive significantly less opioid prescriptions. Third, imaging tends to be lower for patients seeking care from conservative spine clinicians compared to other physicians. Finally, the cost of total care on the health system and out-of-pocket cost for the patient is lowest for patients seeking care from chiropractors. This type of data will become increasingly more important as payers, employers and health systems move more towards value-based care models, with a greater focus on cost, outcomes and satisfaction (The Triple Aim) when making payment and access to care decisions.

References:

  1. Pines JM, Harwood K, Andrilla CH, Frogner BK. Opioid Prescriptions, Radiography, and Costs for Self-Limited “One-and-Done” Lower Back Pain Visits  in a Commercially Insured Population. :7.
  2. Blyth FM, Briggs AM, Schneider CH, Hoy DG, March LM. The Global Burden of Musculoskeletal Pain—Where to From Here? Am J Public Health. 2019;109(1):35-40. doi:10.2105/AJPH.2018.304747
  3. Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. The Lancet. 2018;391(10137):2384-2388. doi:10.1016/S0140-6736(18)30488-4
  4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X

 

Review of Study “Exercise for Chronic Low Back Pain”

Welcome back to Spine IQ’s BackBlog! We are finishing off Women’s History Month by focusing on a study led by Jill Hayden, DC, PhD and her team (3/5 woman co-authors) titled, “Exercise for chronic low back pain.”1 This Cochrane review is an update of Dr. Hayden’s 2005 Cochrane review on the same subject2 and took 10 years to develop as a result of how quickly new studies were being published. It is one of the largest conducted in any health condition, with 13,087 articles screened. Ultimately, 249 studies were analyzed and summarized in this clinically relevant study, which is important for anyone treating, experiencing, or researching chronic low back pain. Feeling overwhelmed by the thought of reading 249 studies that can help you take better care of patients? At Spine IQ we know that while that sheer volume of research conducted for chronic low back pain is exciting, it can also be overwhelming for the busy clinician. That is why we are ‘bringing the research to you” by summarizing Hayden’s Cochrane review (results, benefits, and risks) below.

Objective and Methods

Exercise is recommended as first-line care for chronic low back pain by numerous clinical practice guidelines.3,4 Our previous blogs have discussed how to incorporate exercise in your clinic. However, an updated synthesis of all the exercise for chronic low back pain research had not been done since 2005. The gap in the literature on this topic is well known to anyone attempting to keep up with the exercise for chronic low back pain evidence, made more difficult by the fact that it seems as if a new study is published on this topic every week. As a result, Hayden’s study, published in the prestigious Cochrane library, is one of the most comprehensive reviews every conducted.

Results

After screening more than 13,000 individual studies, 249 unique randomized controlled trials were synthesized. Overall, 107/249 studies compared exercise vs other exercise, while 142/249 compared exercise vs non-exercise. Dr. Hayden and her team found that there is moderate-certainty level of evidence that exercise improves pain and disability. The scales for pain and disability were both on a 0 to 100 point, that means that any change can be interpreted as % change. For example, 1 point change is 1% better improvement than the comparison group. There seems to be a clinically meaningful 15% difference (-15.2 in a scale of 0-100) on pain in favor of exercise compared to no treatment, usual care, or placebo for chronic low back pain. In addition, they found a 9% difference on pain in favor of exercise compared to other conservative treatment (e.g., education, manual therapy, electrotherapy, and psychological). The effects on disability were lower with just under a 7% difference in favor of exercise compared to no treatment, usual care, or placebo and a 4% difference in favor of exercise compared to other conservative treatments (e.g., education, manual therapy, electrotherapy, and psychological). Adverse events were rare, mostly minor (e.g., muscle soreness), and almost as likely to be found in the non-exercise comparison group (29%) in a study compared to the exercise group (33%).

Conclusion

This large, well-conducted systematic review confirms that exercise can be a beneficial treatment with low risk for chronic low back pain and should continue to be incorporated into treatment plans by conservative spine clinicians. While the overall effect may seem to be small, it is important to remember that this effect is in addition to the positive effect of time, regression to the mean, natural history, therapeutic alliance, and other contextual factors. Thus it is likely a difference that is meaningful to patients. Low back pain tends to have an overall good prognosis regardless of the intervention, with most people recovering within 6 weeks.5,6 There is a possibility that delivering exercise may lead to a quicker or overall better (lower pain and better function) recovery when the effect is added on top of the effect of time, other conservative treatments and contextual factors. Take home message? Exercise therapy is an evidence-based treatment for chronic low back pain and is one of the most researched treatments for any condition.
References:

  1. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, Tulder MW van. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;(9). doi:10.1002/14651858.CD009790.pub2
  2. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335. doi:10.1002/14651858.CD000335.pub2
  3. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  4. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  5. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171. doi:10.1136/bmj.a171
  6. Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatol Oxf Engl. 2010;49(12):2346-2356. doi:10.1093/rheumatology/keq245

 

 

Review of Study “The relationship between spinal pain and comorbidity: cross-sectional analysis of community-dwelling, older Australian women.”

Welcome back to SpineIQ’s BackBlog! This week, we are highlighting a WFC-NCMIC Louis Sportelli Research Award winning paper led by Dr. Katie De Luca, titled “The relationship between spinal pain and comorbidity: cross-sectional analysis of community-dwelling, older Australian women.”11 Similar to our previous blogs this month, we are once again honoring Women’s History Month by highlighting important studies led by women investigators.

While we have a lot of research showing the large health and financial burden caused by spine pain.2,3 There is limited research looking at how spine pain is associated with number and type of comorbidities. This is clinically impactful as a higher number of comorbidities influences prognosis, treatment decisions, and referral or co-management decisions.  While spine care clinicians see patients with multiple comorbid conditions every day, many may not think directly about the correlation between spine pain and other serious comorbidities their patients experience.  An opportunity exists for an easy transition for the clinician to ask several questions during the initial clinical intake history, which may provide huge insight into the overall health and progress.  Therefore, Dr. De Luca and her team sought to understand the relationship between spinal pain and comorbidities.

Objective and Methods

579 participants responded to a survey asking them about spinal pain, health-related quality of life and comorbidities. Presence of spinal pain was determined if participants answered “yes” to the question, “which of your joints have been troublesome (painful, aching, swollen, or stiff) on most days of the past month?” Comorbidity is defined as a medical disease either independent or related to the main disease. The type of comorbidity was determined by both self-report question and hospital data confirmation. The comorbidities were grouped into the following categories:

  • cardiovascular disease (heart disease and hypertension),
  • pulmonary disease (bronchitis, emphysema, and asthma),
  • cancer (breast, bowel, skin, and lung cancers)
  • mental disorders (depression, anxiety, and psychiatric illness),
  • obesity
  • diabetes
  • stroke

The Medical Outcomes Study: 36 item short form survey was used to assess health-related quality of life.

Result

Of the 579 participants, 55.8% (n=323) had spinal pain. It is interesting, as well as instructive, to note that participants reporting spinal pain had worse health-related quality of life compared to participants without spinal pain.  Additionally, participants with spinal pain were more likely to have comorbidities compared to people without spinal pain. In fact, people with spinal pain compared to people without spinal pain were significantly more likely by:

  • 44 times to have 2 comorbidities
  • 07 times to have 3 comorbidities
  • 05 times to have 4 comorbidities.

Finally, people with spinal pain compared to people without spinal pain were significantly more likely by:

  • 93 times to have diabetes
  • 57 times to have cardiovascular disease
  • 66 times to have pulmonary disease
  • 60 times to have mental disorder
  • 98 times to be overweight
  • 12 times to have obesity.

Conclusion

As clinicians routinely see in their practice, people with spinal pain are more likely to have comorbidities and be unhealthier compared to people without spinal pain.  This study is an instructive approach to not only educate but make aware of the correlation between spinal pain and co-morbidities, which many patients would not normally associate with spinal pain. Additionally, people with spinal pain reported worse health-related quality of life compared to people without spinal pain. This is important data for conservative spine clinicians to consider as it is essential for clinicians to ask about potential comorbidities for several reasons. First, spinal pain may be stopping patients from being physically active so by decreasing spinal pain and allowing the patient to be more physically active, this can influence these other diseases (e.g., cardiovascular disease and obesity). Second, people with certain comorbidities may be taking certain medications to treat those and some medications given for spinal pain may have unfavorable drug interactions. This places the treatment commonly delivered by conservative spine clinicians (e.g., manual therapy and exercise) as an even more important, first-line treatment. Finally, clinicians may be the first healthcare provider that the patient has seen and therefore, which emphasizes how important it is to properly evaluate patients with spinal pain for other comorbidities given their high correlation with spine pain. This may lead to referral or co-management with other healthcare professionals depending on the suspected comorbidity. This study emphasizes the importance of conservative spine clinicians to continue seeing patients as a whole person, beyond just spinal pain that they may be coming in for.

References:

  1. de Luca KE, Parkinson L, Haldeman S, Byles JE, Blyth F. The Relationship Between Spinal Pain and Comorbidity: A Cross-sectional Analysis of 579 Community-Dwelling, Older Australian Women. J Manipulative Physiol Ther. 2017;40(7):459-466. doi:10.1016/j.jmpt.2017.06.004
  2. Dieleman JL, Cao J, Chapin A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA. 2020;323(9):863-884. doi:10.1001/jama.2020.0734
  3. Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. The Lancet. 2018;391(10137):2384-2388. doi:10.1016/S0140-6736(18)30488-4

 

Review of Study “Chiropractic care for adults with pregnancy-related low back, pelvic girdle pain, or combination pain: a systematic review” Weis et al.

Welcome back to SpineIQ’s Back Blog! This week, we will continue our month-long focus on women- led research for Women History month. Low back pain in pregnancy has been understudied considering the burden and prevalence. A recent study led by Dr. Carol Ann Weis, (with a majority of women co-authors!), titled “Chiropractic care for adults with pregnancy-related low back, pelvic girdle pain, or combination pain: a systematic review”1 attempted to address this gap by increasing the clinician’s understanding of low back pain in pregnancy. If you treat people who experience pregnancy-related low back pain (or experiencing this condition yourself), read below to learn more about treatment considerations!

Objective

Low back pain during pregnancy is common with 30% of women experiencing their first episode of low back pain during pregnancy and approximately 90% of pregnant women having an episode of low back pain.2 The specific cause of pregnancy-related low back pain is likely to be multifactorial, including maternal weight gain, biomechanical changes, and hormonal changes.

There is a need for guidance on best practices in treating pregnancy-related low back pain. This is especially important since many believe that low back pain is normal during pregnancy, resulting in less care-seeking by pregnant women and less attention by clinicians. This systematic review summarizes the available evidence for treatments commonly delivered by chiropractors for pregnancy-related low back pain.

Results

In order to provide comprehensive recommendations for care, study authors focused on treatments that the majority of chiropractors are taught in chiropractic educational programs. They found 50 studies reporting on chiropractic care for pregnancy-related low back pain. While there is some uncertainty in the evidence, the following table summarizes the strength of the evidence for treatments commonly delivered by chiropractors for pregnancy-related low back pain:

 

Treatment Treatment effect (positive, negative, or unknown) Strength of evidence (low, moderate, high, or inconclusive)
Manipulative therapy Positive Moderate
Electrotherapy Positive Moderate
Exercise Positive Inconclusive
Support devices (pillow and belts) Positive Low
Patient education and information Unknown Inconclusive
Multimodal care (manual therapy, exercise, and patient education) Positive Inconclusive

 

Conclusion

While there is a need for more high-quality research regarding chiropractic treatment for pregnancy-related low back pain, there are numerous evidence-based treatments options available. This includes manipulative therapy, electrotherapy, exercise, and support devices. Patient education and information may also be helpful to some patients. Considering the benefit of non-pharmacological care for this specific patient population, chiropractic care can be an important first-line option for pregnant women experiencing low back pain.

References:

  1. Weis CA, Pohlman K, Draper C, daSilva-Oolup S, Stuber K, Hawk C. Chiropractic Care for Adults With Pregnancy-Related Low Back, Pelvic Girdle Pain, or Combination Pain: A Systematic Review. J Manipulative Physiol Ther. 2020;43(7):714-731. doi:10.1016/j.jmpt.2020.05.005
  2. Ostgaard HC, Andersson GBJ. Postpartum Low-Back Pain. Spine. 1992;17(1):53-55.

 

Review of Study “Does Adherence to the Guideline Recommendation for Active Treatments Improve the Quality of Care for Patients With Acute Low Back Pain Delivered by Physical Therapists?”

Welcome back to the Spine IQ Back Blog! March is Women’s History Month, so we are going to highlight low back pain studies that feature woman as first author. This week, we will be discussing a paper by Dr. Julie Fritz that has received an incredible 236 citations since publication in 2007!  As you know from reading our previous blogs, we advocate for clinical practice guidelines and care that is concordant with them. This paper titled, “Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists?” is one of the ground-breaking studies for low back pain and guideline adherence.1

Objective

The burden of low back pain continues to increase with $100+ billion spent by the U.S. healthcare system in 2016 alone.2,3 To curb the disability and cost burden, clinical practice guidelines have been created and implemented.4,5 However, the effects of guideline adherent care on clinical outcomes and cost are unknown. Preliminary studies are demonstrating the cost and outcome benefits of guideline integration into practice protocols.

Methods

Dr. Fritz and her team retrospectively looked at a large dataset of 10 outpatient physical therapy clinics over two years. All adults (18-60 years old) with undergoing treatment for low back pain were examined for clinical outcome, cost, and guideline adherent care. Clinical outcome was assessed by the Oswestry Disability Questionnaire and numeric pain rating scale. Cost was assessed by determining the number of visits and charges for care provided by the billing database. Guideline adherence was determined by dividing care of treatment into two phases, treatment received within the first two weeks (phase 1) and treatments received after day 14 (phase 2). The following treatment was considered guideline adherent and non-adherent:

Phase 1 Guideline Adherent Phase 1 Guideline Non-adherent Phase 2 Guideline adherent Phase 2 Guideline Non-adherent
Therapeutic exercise Ultrasound Therapeutic exercise Ultrasound
Therapeutic activity Hot or cold pack Therapeutic activity Hot or cold pack
Self-care management training Electrical stimulation Self-care management training Electrical stimulation
Neuromuscular re-education Mechanical traction Neuromuscular re-education Mechanical traction
Group therapeutic procedures Massage therapy Group therapeutic procedures Massage therapy
Manual therapy Aquatic therapy with exercise Manual therapy
Aquatic therapy with exercise Gait training therapy
Gait training therapy

 

Results

1190 patients met the criteria of which only 481 (40.4%) received guideline-adherent treatment. Guideline adherent care led to:

  • Shorter symptom duration by an average of 4.7 days
  • Significantly (P = 0.02) fewer visits
  • Significantly (P <0.001) shorter episodes of care
  • 8% better improvement on Oswestry Disability Scale
  • 4% better improvement on numeric pain rating scale
  • Significantly (P <0.001) less physical therapy costs
  • Significantly (64.7% vs 36.5%) more likely to improve by at least 50% from baseline

As you’ll see, some of these are reported as p-values. What this means is that the smaller the p-value then the more likely the finding is due to the treatment and not random chance. Commonly, a p-value of <0.05 is described as statistically significant and anything above that is believed to be insignificant as it is likely due to random chance and not the intervention.

Conclusion

This rigorous study by Dr. Fritz and her team reports the improved clinical and financial outcomes that guideline adherent care delivers. Unfortunately, less than half the patients in this sample received guideline adherent care. It is important that clinicians self-reflect on their own practice, stay up to date with clinical practice guidelines, and continue to work towards care that is guideline adherent. This will allow clinicians to positively impact the growing burden of low back pain. As well as positively impact the reimbursement in a future value-based model of care.

References

  1. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care. 2007;45(10):973-980. doi:10.1097/MLR.0b013e318070c6cd
  2. Dieleman JL, Cao J, Chapin A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA. 2020;323(9):863-884. doi:10.1001/jama.2020.0734
  3. Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. The Lancet. 2018;391(10137):2384-2388. doi:10.1016/S0140-6736(18)30488-4
  4. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
  5. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878

 

Benefits of Chiropractic Care Beyond Pain and Pain-Related Disability

Welcome back to Spine IQ’s Back Blog! Today we are going to talk about a study that provides some insight into why chiropractic care may have an impact that goes beyond low back pain itself. In 2018, Dr. Goertz and her co-authors published a large, pragmatic study that reported the beneficial effects of chiropractic care on pain and pain-related disability.1 However, there are anecdotal reports from both patients and clinicians that chiropractic care can have additional beneficial effects on quality of life. To address this issue, Goertz et al included secondary measures in the study mentioned to evaluate the impact of chiropractic treatment on conditions such as anxiety, depression and fatigue using the PROMIS 29 questionnaire. In this week’s blog, we are going to discuss these findings, which were recently published in Pain Medicine.2

Objective

Low back pain continues to be the leading cause of disability and costliest condition in the United States.3,4 In an attempt to intervene on the health concerns and cost burden of low back pain, clinical practice guidelines consistently recommend interventions commonly delivered by chiropractors such as spinal manipulation, exercise, advice, and education.5,6 Most studies evaluating chiropractic care assess the effect on pain and pain-related disability. While these are important measures, there is a growing need to understand the effect of chiropractic care on measures that impact health related quality of life including sleep, anxiety, depression, satisfaction, physical function, and pain interference. The recently published study collected  data from a large (n=750) population of patient with low back pain in order to compare usual medical to usual medical care plus chiropractic care. As this was a pragmatic study, all clinicians (medical and chiropractic) were able to treat patients as they would normally, without additional study requirements or restrictions.

Results

In this study, chiropractors delivered spinal manipulation to all participants followed by exercise (49%), electrical muscle stimulation (47%), hot or cold packs (47%), mechanical traction (23%), and other manual therapy (23%). Adding chiropractic care to the usual medical care pathway led to significant benefit for patients in terms of physical function, pain interference, sleep disturbance, anxiety, depression, and satisfaction. While chiropractic care was still beneficial, the smallest effects were seen for sleep and depression. Consistent with other studies, the largest benefits were found for pain interference.7 The study authors hypothesize that conditions such as sleep, anxiety, and depression may improve due to a decrease in pain. Future studies are needed to identify additional rationale for these findings.

Conclusion

This study provides additional evidence that chiropractic care may lead to beneficial effects for patients with low back pain when added to usual care.

References:

  1. Goertz CM, Long CR, Vining RD, Pohlman KA, Walter J, Coulter I. Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial. JAMA Netw Open. 2018;1(1):e180105. doi:10.1001/jamanetworkopen.2018.0105
  2. Hays RD, Shannon ZK, Long CR, et al. Health-related quality of life among United States service members with low back pain receiving usual care plus chiropractic care plus usual care vs usual care alone: Secondary outcomes of a pragmatic clinical trial. Pain Med Malden Mass. Published online January 21, 2022:pnac009. doi:10.1093/pm/pnac009
  3. Dieleman JL, Cao J, Chapin A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA. 2020;323(9):863-884. doi:10.1001/jama.2020.0734
  4. GBD 2016 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Lond Engl. 2017;390(10100):1260-1344. doi:10.1016/S0140-6736(17)32130-X
  5. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
  6. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  7. Saragiotto BT, Maher CG, Traeger AC, Li Q, McAuley JH. Dispelling the myth that chronic pain is unresponsive to treatment. Br J Sports Med. 2017;51(13):986-988. doi:10.1136/bjsports-2016-096821