Frank M. Painter

Addressing The Burden Of Spine-Related Disorders Through Integrated Value-Based Care

By Frank M. Painter|February 19, 2025|Cost-Effectiveness of Chiropractic, Integrative Care, Nonpharmacologic Therapies|

Addressing The Burden Of Spine-Related Disorders Through Integrated Value-Based Care

SOURCE: Health Affairs Forefront, February 12, 2025

Ryan Burdick • Christian Péan Sara • Holleran Inga Morken • Christine Goertz

Faculty of Health Sciences,
Ontario Tech University.

Editor’s Note:

This article is the latest in the Health Affairs Forefront series, Accountable Care for Population Health, featuring analysis and discussion of how to understand, design, support, and measure patient-centered, cost-efficient care under the umbrella of accountable care. Readers are encouraged to review the Call for Submissions for this series. We are grateful to Arnold Ventures for their support of this work.

The unsustainable rise of health care costs in the US, coupled with suboptimal health outcomes, is driving both conversation and real action toward value-based care (VBC) models in this country. There is no more low-hanging fruit for this effort than spine-related disorders. Low back and neck pain cost us more than $134 billion annually and continues to rise at a rate more than twice that of overall health spending despite the fact that it is already at or near the top of all direct health care expenditures.

Despite aggressive and often invasive treatment approaches, low back pain remains the leading cause of physical disability worldwide with neck pain not far behind. This divergence between cost and outcomes is driven largely by the sustained use of expensive and ineffective treatments that can lead to more harm than benefit. Overreliance on prescription opioids began in the early 2000s, based on weak evidence suggesting that these medications were safe and effective treatments. In addition, the US maintains a higher rate of surgical interventions, more frequent specialist consultations for initial diagnoses, and consistently higher use of medically unnecessary advanced imaging.

Recognizing the profound impact of spine-related disorders, organizations including the

American College of Physicians, the

Centers for Disease Control and Prevention, the

World Health Organization

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Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study

By Frank M. Painter|February 9, 2025|Chiropractic Care, Medicare|

Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study

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SOURCE: J Manipulative Physiol Ther 2021 (Mar)

James M Whedon • Scott Haldeman • Curtis L Petersen • William Schoellkopf • Todd A MacKenzie • Jon D Lurie

Health Services Research,
Southern California University of Health Sciences,
Whittier, California.

FROM: Davis ~ J Am Board Fam Med. 2015 (Jul)

Objective: Spinal manipulation (SM) is recommended for first-line treatment of patients with low back pain. Inadequate access to SM may result in inequitable spine care for older US adults, but the supply of clinicians who provide SM under Medicare is uncertain. The purpose of this study was to measure temporal trends and geographic variations in the supply of clinicians who provide SM to Medicare beneficiaries.

Methods: Medicare is a US government-administered health insurance program that provides coverage primarily for older adults and people with disabilities. We used a serial cross-sectional design to examine Medicare administrative data from 2007 to 2015 for SM services identified by procedure code. We identified unique providers by National Provider Identifier and distinguished between chiropractors and other specialties by Physician Specialty Code. We calculated supply as the number of providers per 100,000 beneficiaries, stratified by geographic location and year.

Results: Of all clinicians who provide SM to Medicare beneficiaries, 97% to 98% are doctors of chiropractic. The geographic supply of doctors of chiropractic providing SM services in 2015 ranged from 20/100,000 in the District of Columbia to 260/100,000 in North Dakota. The supply of other specialists performing the same services ranged from fewer than 1/100,000 in 11 states to 8/100,000 in Colorado. Nationally, the number of Medicare-active chiropractors declined from 47 102 in 2007 to 45 543 in 2015. The count of other clinicians providing SM rose from 700 in 2007 to 1441 in 2015.

Conclusion: Chiropractors constitute the vast majority of clinicians who bill for SM services to Medicare beneficiaries. The supply of Medicare-active SM providers varies widely by state. The overall supply of SM providers under Medicare is declining, while the supply of nonchiropractors who provide SM is growing.

Keywords: Chiropractic; Manipulation, Spinal; Medicare; Musculoskeletal Manipulations.

From the FULL TEXT Article:

Introduction

Low back pain is highly prevalent in the United States, and management of it can be particularly challenging in the Medicare beneficiary population, which is older and has disabilities and frequently comorbidities. [1, 2]

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Association Between Chiropractic Spinal Manipulation for Sciatica and Opioid-related Adverse Events: A Retrospective Cohort Study

By Frank M. Painter|January 31, 2025|Adverse Drug Reactions, Adverse Events, Chiropractic Management, Low Back Pain, Opioid Epidemic, Sciatica|

Association Between Chiropractic Spinal Manipulation for Sciatica and Opioid-related Adverse Events: A Retrospective Cohort Study

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SOURCE: PLoS One 2025 (Jan 28); 20 (1): e0317663

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Robert J. Trager • Zachary A. Cupler • Roshini Srinivasan • Elleson G. Harper • Jaime A. Perez

Connor Whole Health,
University Hospitals Cleveland Medical Center,
Cleveland, Ohio, United States of America.

Background: Patients receiving chiropractic spinal manipulation (CSM) for spinal pain are less likely to be prescribed opioids, and some evidence suggests that these patients have a lower risk of any type of adverse drug event. We hypothesize that adults receiving CSM for sciatica will have a reduced risk of opioid-related adverse drug events (ORADEs) over a one-year follow-up compared to matched controls not receiving CSM.

Methods: We searched a United States (US) claims-based data resource (Diamond Network, TriNetX, Inc.) of more than 216 million patients, yielding data ranging from 2009 to 2024. We included patients aged ?18 years with sciatica, excluding those post-spine surgery, prior anesthesia, serious pathology, high risk of ORADEs, and an ORADE ? 1-year prior. Patients were divided into two cohorts: (1) CSM and (2) usual medical care. We used propensity score matching to control for confounding variables associated with ORADEs. Comparative outcomes were analyzed by calculating risk ratios (RRs) and 95% confidence intervals (CIs) for the incidence of ORADEs and oral opioid prescription between cohorts.

Results: 372,471 patients per cohort remained after matching. The incidence of ORADEs over 1-year follow-up was less in the CSM cohort compared to the usual medical care cohort (CSM: 0.09%; usual medical care: 0.30%), yielding an RR of 0.29 (95% CI: 0.25-0.32; P < .00001). CSM patients had a lower risk of receiving an oral opioid prescription (RR of 0.68 [95% CI: 0.68-0.69; P < .00001]).

Conclusions: This study found that adults with sciatica who initially received CSM had a lower risk of an ORADE compared to matched controls not initially receiving CSM, likely explained by a lower probability of opioid prescription. These findings corroborate existing practice guidelines which recommend adding CSM to the management of sciatica when appropriately indicated.

From the FULL TEXT Article:

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Comparative Effectiveness of Cervical vs Thoracic Spinal-thrust Manipulation for Care of Cervicogenic Headache: A Randomized Controlled Trial

By Frank M. Painter|December 26, 2024|Cervicogenic Headache, Chiropractic Care|

Comparative Effectiveness of Cervical vs Thoracic Spinal-thrust Manipulation for Care of Cervicogenic Headache: A Randomized Controlled Trial

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SOURCE: PLoS One 2024 (Mar 29); 19 (3): e0300737 ~ FULL TEXT

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Gopal Nambi • Mshari Alghadier • Mudathir Mohamedahmed Eltayeb • Osama R Aldhafian. et al.

Department of Health and Rehabilitation Sciences,
College of Applied Medical Sciences,
Prince Sattam Bin Abdulaziz University,
Al-Kharj, Saudi Arabia.

Background: There is ample evidence supporting the use of different manipulative therapy techniques for cervicogenic headache (CgH). However, no technique can be singled as the best available treatment for patients with CgH. Therefore, the objective of the study is to find and compare the clinical effects of cervical spine over thoracic spine manipulation and conventional physiotherapy in patients with CgH.

Design, setting, and participants: It is a prospective, randomized controlled study conducted between July 2020 and January 2023 at the University hospital. N = 96 eligible patients with CgH were selected based on selection criteria and they were divided into cervical spine manipulation (CSM; n = 32), thoracic spine manipulation (TSM; n = 32) and conventional physiotherapy (CPT; n = 32) groups, and received the respective treatment for four weeks. Primary (CgH frequency) and secondary CgH pain intensity, CgH disability, neck pain frequency, neck pain intensity, neck pain threshold, cervical flexion rotation test (CFRT), neck disability index (NDI) and quality of life (QoL) scores were measured. The effects of treatment at various intervals were analyzed using a 3 × 4 linear mixed model analysis (LMM), with treatment group (cervical spine manipulation, thoracic spine manipulation, and conventional physiotherapy) and time intervals (baseline, 4 weeks, 8 weeks, and 6 months), and the statistical significance level was set at P < 0.05.

Results: The reports of the CSM, TSM and CPT groups were compared between the groups. Four weeks following treatment CSM group showed more significant changes in primary (CgH frequency) and secondary (CgH pain intensity, CgH disability, neck pain frequency, pain intensity, pain threshold, CFRT, NDI and QoL) than the TSM and CPT groups (p = 0.001). The same gradual improvement was seen in the CSM group when compared to TSM and CPT.

Conclusion: The reports of the current randomized clinical study found that CSM resulted in significantly better improvements in pain parameters (intensity, frequency and threshold) functional disability and quality of life in patients with CgH than thoracic spine manipulation and conventional physiotherapy.

Trial registration: Clinical trial registration: CTRI/2020/06/026092 trial was registered prospectively on 24/06/2020.

From the FULL TEXT Article:

Introduction

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Clinician Experiences in Providing Reassurance for Patients with Low Back Pain in Primary Care: a Qualitative Study

By Frank M. Painter|December 24, 2024|Low Back Pain|

Clinician Experiences in Providing Reassurance for Patients with Low Back Pain in Primary Care: a Qualitative Study

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SOURCE: J Physiotherapy 2024 (Dec 12): [EPUB]

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Anika Young • Simon D French • Adrian C Traeger< Julie Ayre • Mark Hancock • Hazel J Jenkins
Department of Chiropractic,
Faculty of Medicine, Health and Health Science,
Macquarie University,
Sydney, Australia.

Questions: What reassurance is being delivered by physiotherapists and chiropractors to people with non-specific low back pain? How is it being delivered? What are the barriers and enablers to delivering reassurance to people with non-specific low back pain?

Design: A qualitative study.

Participants: Thirty-two musculoskeletal clinicians (16 physiotherapists and 16 chiropractors) who manage low back pain in primary care.

Method: Semi-structured interviews were conducted about their experiences delivering reassurance. The interview schedule was developed using the Theoretical Domains Framework and analysed using framework thematic analysis.

Results: Four themes were identified: giving reassurance is a core clinical skill for delivering high-quality care; it takes practice and experience to confidently deliver reassurance; despite feeling capable and motivated, clinicians identified situations that challenge the delivery of reassurance; and reassurance needs to be contextualised to the individual.

Conclusion: Clinicians possess a strong understanding of reassurance but require clinical experience to confidently deliver it. This study provides insights into how reassurance is individualised in clinical practice, including suggestions for clinicians about how to implement reassurance effectively for people with low back pain.

Keywords: Low back pain; Primary healthcare; Qualitative research; Reassurance.

From the FULL TEXT Article:

Introduction

Low back pain (LBP) is common and is associated with substantial disability. Worldwide, 619 million people experienced back pain in 2020, [1] and there are significant personal and societal costs related to LBP. [2, 3] In Australia, back pain continues to be the second leading cause of disability [4] and back pain management cost AU$3.36 billion in 2020. [4] The prevalence of LBP has been projected to increase over the next 25 years, with associated increases in disability with healthcare costs. [1] Most LBP is non-specific low back pain (NSLBP), referring to LBP that does not have a known pathoanatomical cause. [5] LBP is a complex condition that is multifactorial in nature, where a person’s pain experience is influenced by biological, psychological and social factors. [6] Recovery from an episode of LBP is also complex; approximately 25% of people with LBP experience recurrence within 12 months [7] and 44% of people can still experience pain at 12 months. [8]

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Proprioceptive Cervicogenic Dizziness: A Narrative Review of Pathogenesis, Diagnosis, and Treatment

By Frank M. Painter|December 22, 2024|Cervicogenic Dizziness, Chiropractic Management|

Proprioceptive Cervicogenic Dizziness: A Narrative Review of Pathogenesis, Diagnosis, and Treatment

The Chiro.Org Blog

SOURCE: J Clinical Medicine 2022 (Oct 26); 11 (21): 6293
Yongchao Li • Liang Yang • Chen Dai • Baogan Peng

The Third Medical Centre of Chinese PLA General Hospital,
Department of Orthopedics,
69 Yongding Road,
Beijing 100039, China.

FROM: J Orthop Sports Phys Ther 2009

Basic science and clinical evidence suggest that cervical spine disorders can lead to dizziness. The cervical spine has highly developed proprioceptive receptors, whose input information is integrated with the visual and vestibular systems in the central nervous system, acting on the neck and eye muscleThere are many more studiess to maintain the coordinative motion of the head, eyes, neck, and body through various reflex activities.

When the cervical proprioceptive input changes due to the mismatch or conflict between vestibular, visual, and proprioceptive inputs, cervicogenic dizziness may occur. The diagnosis of cervicogenic dizziness can be determined based on clinical features, diagnostic tests, and the exclusion of other possible sources of dizziness. The cervical torsion test appears to be the best diagnostic method for cervicogenic dizziness.

Based on the available evidence, we first developed the diagnostic criteria for cervicogenic dizziness. Treatment for cervicogenic dizziness is similar to that for neck pain, and manual therapy is most widely recommended.

Keywords: cervical proprioception; cervicogenic dizziness; diagnosis; management; neck pain; proprioceptors.

From the FULL TEXT Article:

Introduction

Dizziness is one of the most common reasons for consultation in adult patients. [1, 2] It is an umbrella term used to describe various sensations, including vertigo, disequilibrium, lightheadedness, or presyncope (Table 1). [2] From this perspective, vertigo is just one part of dizziness. However, in the light of the International Bárány Society for NeuroOtology [3], dizziness and vertigo are no longer subordinate but independent allelic symptoms. Dizziness and vertigo may coexist or occur sequentially (Table 2). [3] In 1955, Ryan and Cope [4] first described dizziness caused by neck disorders as cervical vertigo, also known as cervicogenic vertigo, cervicogenic dizziness or cervical dizziness. In this review, we use cervicogenic dizziness to name this trouble. A recent clinical observation of a large number of cases (1,000 cases) found that cervicogenic dizziness accounted for 89% of all dizziness, or vertigo. [5] Cervical spondylosis was one of the common causes of dizziness in the elderly in a community survey. [1] Among patients with cervical vertebral whiplash injuries, the prevalence of dizziness has been variously reported, ranging from 20% to 90%. [6] Nearly half of patients with neck pain have cervicogenic dizziness. [1] However, cervicogenic dizziness is the most controversial among all dizziness because its pathogenesis is unclear, and its diagnosis and treatment are difficult. [6-9]

Cervicogenic dizziness is considered to have four different pathogenesis, but proprioceptive cervicogenic dizziness is the most common and accepted by most scholars. [6] Unlike other forms of dizziness, cervicogenic dizziness is of interest not only to neurologists but also to physiotherapists, pain physicians, and orthopedic surgeons. The purpose of this narrative review is to highlight the pathophysiology, diagnosis, and treatment of cervicogenic dizziness from the perspective of the cervical proprioceptive afferent disorder.

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About Frank M. Painter

Addressing The Burden Of Spine-Related Disorders Through Integrated Value-Based Care

Addressing The Burden Of Spine-Related Disorders Through Integrated Value-Based Care

Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study

Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study

Association Between Chiropractic Spinal Manipulation for Sciatica and Opioid-related Adverse Events: A Retrospective Cohort Study

Association Between Chiropractic Spinal Manipulation for Sciatica and Opioid-related Adverse Events: A Retrospective Cohort Study

Comparative Effectiveness of Cervical vs Thoracic Spinal-thrust Manipulation for Care of Cervicogenic Headache: A Randomized Controlled Trial

Comparative Effectiveness of Cervical vs Thoracic Spinal-thrust Manipulation for Care of Cervicogenic Headache: A Randomized Controlled Trial

Clinician Experiences in Providing Reassurance for Patients with Low Back Pain in Primary Care: a Qualitative Study

Clinician Experiences in Providing Reassurance for Patients with Low Back Pain in Primary Care: a Qualitative Study

Proprioceptive Cervicogenic Dizziness: A Narrative Review of Pathogenesis, Diagnosis, and Treatment

Proprioceptive Cervicogenic Dizziness: A Narrative Review of Pathogenesis, Diagnosis, and Treatment