With opioid misuse or overuse remaining a major concern in Australia, the USA and other developed countries, it seems the light is shining on other ways to manage pain and improve function in chronic pain patients. Devotees of chiropractic and other manual therapies may already be reaping the rewards of care, but it seems we have a way to go before our offering is well understood by the wider chronic pain population. To this end, a new piece of research has used observational data to break down an interesting topic: what are the predictors of visit frequency for chronic low back and neck pain patients, and what needs to happen in order to improve these numbers?
Ask any chiropractor: it’s not about numbers per se. Nor is it strictly about pain reduction. In an ideal scenario, chiropractic care for pain reduction is just the beginning of a much longer journey that can lead from pain reduction, to improved function, and ultimately optimal nervous system function and the expression of wellness. The numbers simply tell us whether our message is reaching the people who need to hear it. And quite frankly, this has been a challenge over the years.
That’s what makes the study, published on BioMed Central, an interesting insight into the work that needs to be done to widen the net. Though it does focus on chronic low back pain and neck pain (the most common types of chronic pain), it is very much a gateway to a broader discussion about the topic.
Chronic low back pain and chronic neck pain are the most common types of chronic pain, with a combined prevalence of 1–20%. Of course, there is substantial comorbidity associated with this level of pain, the implications of which reach from the economics of the public healthcare system to an individual’s professional and personal life. While the big thinkers grapple with ways to reduce the use of opioids, attention has been refocused on nonpharmacologic therapies and how they can lessen the burden (especially when it comes to chronic pain syndromes).
The paper, which can be found at the reference below, argues that the way chronic pain is approached by health care policies is also not very supportive of ongoing treatment and is based on a curative model of treatment. While it was focused on an American sample, the same could be said of Australia and other countries. We want the pain to go, but that’s where the buck seems to stop in terms of policy and funding.
The paper sought information on how to best support ongoing pain management, and potentially reframe some of the current policies in place (i.e. the current thinking of needing to see continued improvement to continue treatment and discontinuing treatment discontinued at a plateau of maximum benefit). Some policies recognise ongoing care may be needed if symptoms deteriorate after treatment stops but little guidance is provided for care under these circumstances. At this point, if the person under care wants to keep improving function (as in the case of many chiropractic patients), they do so at their own cost.
THE STUDY DETAILS
In order to examine the current situation and formulate recommendations, the authors of the study collected observational data over three months of a national sample of US chiropractors and their patients with chronic neck or low back pain. A total of twenty chiropractic clinics were selected and their patients recruited. To ensure the validity of the study, they made sure the sample was representative of chiropractor’s gender, years of experience and patient loads. To be included in the study, patients had to meet exclusion criteria that ensured they were proficient in English, not on workers compensation or personal injury litigation, and they had to have low back and neck pain lasting more than three months before starting chiropractic care. There was also a list of other medical conditions that had to be absent so as not to skew the data away from the core issue.
Consenting, eligible participants then undertook a baseline survey followed by shorter, biweekly follow-ups to collect data on ongoing care and symptoms, as well as a longer endpoint survey at the three months. The sample group was split into those with chronic low back pain (CLBP) and chronic neck pain (CNP). While some participants both, they were assigned to the group of whichever pain was worse.
In terms of measures:
- Visit frequency was defined as the average number of chiropractic visits per 30-day month.
- The study measured baseline insurance coverage and out-of-pocket costs.
- Patients’ needs were characterised by numerical rating of pain and the 10-item neck disability index for those with neck pain, or the 10-item Oswestry disability index for those with back pain.
- Duration of pain and whether they had both the neck and back pain were also included.
The research indicates that having both type of chronic pain results in worse outcomes and the duration of pain may be a justification of ongoing care and thus an indicator. For visit frequency. Some lifestyle characteristics could also be included, if a person’s work is very physically demanding it may justify ongoing care even according to an allopathic or pain-based model of care (By contrast, many chiropractors operate on a model of care that is oriented towards improvements in function and increased nervous system optimisation).
Patients’ goals for their treatment may affect their visit frequency and so was included on the surveys, as was pain belief, whether they thought it was chronic or what would happen if they didn’t receive treatment.
Psychological factors may also affect perceived ‘need’ for care and visit frequency. Patients’ self-efficacy for their pain management was measured at baseline using a 5-item subscale of the chronic pain self-efficacy scale. Other psychological conditions also measured such as anxiety, depression and catastrophizing. An expectancy questionnaire was also done to in order to evaluate how much improvement patients expected to see over the next three-months. Predisposing factors including age, gender, and education were also included in the scope of the research.
HERE IS WHAT THEY FOUND:
Keeping in mind this study was carried out in the USA, insurance was found to be significant. Having some insurance coverage increases visit frequency by 0.44 visits per month for patients with chronic low back pain but not chronic neck pain. While comparisons have not been made to the Australian system, it is possible that private health cover may create similar indicators in the Australian population.
Other factors that increased visit frequency included:
- Having significantly worse function
- Being a newer patient
- Those with chronic low back pain who undertook heavy labour at work
Interestingly, being female decreased visit frequency. Another fascinating finding was that, when all patient characteristics were accounted for, the characteristics of the chiropractor had significant explanatory power to patients’ visit frequency. For example:
- Chiropractors who had higher volumes of patients per day also had higher visit frequencies per patient involved in the study.
- By contrast, this was significantly lower for chiropractors with 20-30 years experience.
- Higher visit frequencies were recorded for those with Chronic Neck Pain when the chiropractor reported treating a higher proportion of patients for maintenance or preventative care.
- Average visit frequency was 2.3 chiropractic visits per month but varied greatly by the characteristics of the patients, treating chiropractors, and location (US state in this case)
By and large, the study appears to reveal that it is a combination of patient and chiropractor factors that contribute to visit frequency. While the surveys did not dig into the specific philosophies or techniques underpinning each chiropractic clinic, it still proves interesting.
Overall, it appears that the conditions are ripe for discussions about policies regarding chiropractic care and other non-pharmacological or opioid based treatments for chronic pain. However, it also appears that the individual chiropractor can be just as impactful when it comes to influencing visit frequency as pain itself.
There is a world of possibilities not yet covered by research in that fact alone: chiropractic communication, orthopaedic or neurological based practices, philosophy, vitalistic practice or mechanistic practice and much more. Why chiropractor influences patient frequency is certainly a matter for further research, but for now, it is a factor to be cognizant of.
The study’s importance lies in the fact that “Chiropractic patients with [chronic low back pain] and [chronic neck pain] manage their pain using a range of visit frequencies and the predictors of these frequencies could be useful for developing policies for ongoing provider-based care.” As policy makers and healthcare providers across the developed world grapple with the opioid crisis, this paper certainly makes for an informative starting point to understanding how best to engage with the chronic pain population.
It would certainly be nice to see future research delve into outcomes experienced by these patients (which would be important for the development of effective policies), and seems to indicate that there are some methods of chiropractic communication and/or practice that reap different results in terms of visit frequency.
It will certainly be interesting to see what emerges.
- Herman, P.M., Edgington, S.E., Hurwitz, E.L. et al. Predictors of visit frequency for patients using ongoing chiropractic care for chronic low back and chronic neck pain; analysis of observational data. BMC Musculoskelet Disord 21,298. 2020