Monday, December 29, 2014

How Much Chiropractic Manipulation is Optimal?

A constant of workers' compensation is limitation and definition. Everything that is or is not workers' compensation is statutory, and those statutes are periodically amended and refined. In 1993, the Florida Legislature made significant changes to the workers' compensation law. Some of those revisions survive still. Fla. Stat. §440.13(2)(a) came to mind recently. 

The 1993 revisions, for the first time in Florida, restricted the provision of workers' compensation chiropractic care. Chiropractic care became limited to "18 treatments or rendered 8 weeks beyond the date of the initial chiropractic treatment, whichever comes first." In 2003, this was enlarged to 24 treatments or 12 weeks. The statute currently reads:

"Medically necessary treatment, care, and attendance does not include chiropractic services in excess of 24 treatments or rendered 12 weeks beyond the date of the initial chiropractic treatment, whichever comes first, unless the carrier authorizes additional treatment or the employee is catastrophically injured."

Whenever there are set parameters, it is likely that some part of the population may need something more or less than the parameter. Human beings are incredibly complex, and as much as we have similarities with each other there are a million ways in which we may each be different. How we each respond or do not respond to medical treatment, exercise, diet, are among these. 

In December, Workcompcentral.com reported on a study regarding chiropractic care that was published in The Spine Journal. This was a randomized study of "400 participants with nonspecific" low back pain. They were provided with "a dose of  0, 6, 12, or 18 spinal manipulation therapy (SMT) sessions from a chiropractor." The study explains that each participant received "18 treatment visits, 3 per week for 6 weeks," and on appointments where a particular patient did not receive SMT, she or he received "brief light massage." Thus, all participants attended 18 visits, but not all received 18 SMT. 

The researchers followed-up with the patients to collect "self-reported pain intensity and functional disability at the 12- and 24-week end points." These were selected "to emphasize a short- and a long-term post-treatment time point." So, the participants were provided either massage or manipulation to varying extents, and then each was asked about their abilities and pain at both 12 and 24 weeks. 

So there is a degree of subjectivity to the study. Some might criticize the study for thus being largely dependent upon self-reported results. The report's validity is supported though by its breadth, 400 patients is a large population. There is also some validity support suggested by the completion rate; the report indicated that 90-95% of the participants attended "all 18 study visits." So a significant population with a significant completion rate. 

The best "treatment effects" were yielded by "12 sessions of SMT" (spinal manipulation therapy). The study concludes that "the data were consistent with a dose-response relationship being saturated at 12 sessions with little or no additional benefit attributable additional SMT visits." The report explains that there was some medical benefit even from the massage therapy (the alternative appointment purpose for those who did not receive SMT on a particular visit). The authors concluded that "sessions with even minimal massage may have more effect than one might expect." 

The study concludes that "overall, 12 sessions of spinal manipulation in 6 weeks from a chiropractor yielded the most favorable pain and functional disability improvement for chronic nonspecific LBP (low back pain").

Twelve sessions in 6 weeks is within the scope of Fla. Stat. §440.13 (2)(a), which limits chiropractic in many workers' compensation cases to 24 treatments or 12 weeks. None of the study participants received what is allowed by Florida law. The maximum in the study was 18 treatments in 6 weeks; a maximum of 75% of visits in 50% of the time allowed in Florida. 

Is the study vindication for the various state's legislative parameters restricting chiropractic care? I knew a lady years ago who received chiropractic care at her own expense. She went weekly for years, and swore by it. Her experience may be an outlier, and is not scientific like the study. It is anecdotal, but still makes me wonder about the study results. 


The Spine Journal is only one study. As the various television ads have cautioned over the years, "your results may vary." However, it is at least interesting. I will be curious to see future studies and whether they validate or call in to question the Journal results. 

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