|
The Burden of Musculoskeletal Disorders
Musculoskeletal conditions have been
identified as a significant economic burden and a major
cause of morbidity throughout the world.1
The significant burden to society of
musculoskeletal disorders has resulted in the United
Nations declaring 2000 to 2010 as The Bone and Joint
Decade.1,2 In Canada, the total direct and indirect cost
of musculoskeletal disorders exceeds those reported for
cardiovascular disease with the highest costs reported
for injuries, back and spine disorders, arthritis and
rheumatism.3 Consequently, it is important that
appropriate, effective and cost-effective treatment be
provided for such a significant contributor to health
care expenditures. What role can chiropractors play in
treating these conditions? Chiropractic doctors are
primary contact health care professionals trained to
diagnose and treat neuromusculoskeletal conditions. They
can participate effectively within the multidisciplinary
health care setting to provide effective treatment for
spinal and peripheral musculoskeletal complaints.
Incidence and Quality of Life
The annual incidence of musculoskeletal
disorders was recently determined to be 13.6% in the
spine, 4.2% in a joint and 4.6% at an extra-articular
site.4 Individuals with musculoskeletal disorders
experience pain, lose physical function and have a
reduced quality of life. New onset of musculoskeletal
conditions has marked deleterious effects on quality of
life in the physical domain, and lesser effects on
social and mental functioning.4
Back Pain
Back pain, especially low back pain,
accounts for the majority of presentations seen in
chiropractic practices.5 The population prevalence of
experiencing at least one back pain episode within a
persons lifetime is 58% to 84%.1,3,5,6 Any structure in
the back and neck that is innervated, including the
facet and sacroiliac joints, intervertebral discs, bone,
ligaments, and muscles, can be a cause of pain.5 A
disabling episode of low back pain occurs in
approximately 11% of the adult population in any six
month period.6 Disability can negatively affect all
quality of life aspects as well as function within
occupational settings. Although musculoskeletal
occupational injuries of the extremities occur,
occupational back pain is the most common and costly
work-related injury.7 A multidisciplinary rehabilitation
program with exercise is indicated for the treatment of
low back pain that includes a workplace visit or a more
comprehensive occupational health care intervention to
help patients return to work faster, minimize sick leave
and alleviate subjective disability.8,9,10
Neck Pain
Neck pain closely follows back pain in
lifetime prevalence at 65% and an annual incidence of
almost 15% in Canada.11,12 Clinically important factors
found to be associated with neck pain include a history
of whiplash injury, headache, depression, cardiovascular
disease, digestive disorders and cigarette smoking.13 A
recent Cochrane review suggested that mobilization
and/or manipulation when used with exercise are
beneficial for persistent mechanical neck disorders with
or without headache.14 Whiplash injuries, being the most
common following motor vehicle collisions, are a
significant health problem and a cause of chronic
disability.15 The comprehensive systematic review of
literature undertaken by the Quebec Task Force on
Whiplash Associated Disorders, and more recent
systematic reviews, recommend mobilization and/or
manipulation for whiplash-associated disorders.15 Neck
pain can result in absenteeism from work and disability
although it is usually less disabling than low back
pain.16
Chiropractors are trained to treat patients with neck
and back pain with multimodal manual therapy, education
and referral for co-treatment for conditions that
require multidisciplinary management.
Headache
Headache prevalence varies with the type
of headache, its severity, frequency and disability. The
one-year prevalence of tension-type headache, the most
common type of headache, ranges from 40% to 80%.17
Those who experience tension-type
headaches report work loss and decrease in quality of
life including decreased effectiveness at work, home or
school. Migraine headaches are less common with one-year
prevalence of 10% to 12%, but they tend to be more
severe and disabling.17
Osteoarthritis
As the population ages and includes more
geriatric patients, the prevalence of osteoarthritis and
other musculoskeletal disorders will also increase
creating an even greater impact on society.
Osteoarthritis is already the fourth most frequent
predictor of health problems worldwide in women and
eighth most common in men.18 Osteoarthritis can affect
spinal and peripheral joints especially those that are
involved in weight-bearing. In the geriatric population,
the goal of treatment is to prevent or delay functional
decline and maintain quality of life by restoring
function to allow as much independent living as
possible.5 Peripheral and spinal muscles and ligaments
can also be injured by activities of daily living,
occupational, sports and recreational activities leading
to various cumulative or single-trauma strains and
sprains.
Referral Indications
Acute and chronic neck and back
pain
Chronic headaches
Whiplash associated disorder (WAD)
Musculoskeletal complaints of the
geriatric population (i.e. osteoarthritis)
Early conservative therapy for
lumbar stenosis or disc herniation
Strains and sprains
Occupational, sport-related and
recreational musculoskeletal injuries
Chiropractic Treatment Modalities
The treatment methods commonly used by
chiropractors to treat musculoskeletal disorders are
based on best practice and best evidence. They are
typically multimodal14 and may include:
Manual therapies joint
manipulation, mobilization, and soft tissue
therapies;
Electrotherapeutic modalities
ultrasound, inferential current or low level laser;
Rehabilitation strategies
exercise and behavioural modifications.5
Multimodal treatment is recommended in
work-related injuries accompanied by communication with
the employer to encourage progress through a modified
working environment.8,9
Effectiveness and Safety
The effectiveness of chiropractic
treatment has been studied extensively. In fact,
manipulation is one of the most studied forms of
conservative treatment for spinal pain.19 Systematic
reviews demonstrate manipulation as an effective
treatment for back and neck complaints.14,20
Manipulation, as well as multimodal and
multidisciplinary care, are also recommended by the
evidence-based guidelines facilitated by the College of
Physicians and Surgeons (Ontario) for chronic
non-malignant neck and back pain.21 In a recent
pragmatic randomized trial (UK BEAM) for low back pain,
manipulation was found to be an effective and
cost-effective addition to best care in general
practice, either alone or with exercise.22,23 In terms
of neck pain, mobilization and/or manipulation are
recommended by the Quebec Task Force and recent reviews
as treatments for whiplash associated disorders.15
Spinal mobilization has also been demonstrated to be
more cost-effective for neck pain in comparison to
general practitioner care and physical therapy.16 For
the treatment of chronic tension-type and migraine
headaches, manipulation has been found to be effective
with fewer side-effects than medications.17 Manipulation
has also been found to be more effective than massage
for cervicogenic headaches.17
In terms of general health care
utilization, patients with chiropractic insurance
coverage have lower annual total health care
expenditures compared to those without.24
Chiropractic coverage is also associated with lower
utilization of imaging studies, hospitalizations and
lower average back pain episode-related costs.24
Chiropractic treatment is covered by all provincial
Workers Compensation Boards. A recent evaluation report
on the Ontario Workers Safety and Insurance Board,
Program of Care for Acute Low Back Injuries demonstrated
that patients undergoing chiropractic care have fewer
lost work days and more clinically significant
improvement in pain and disability compared to those in
physiotherapy.25 Patients consistently report
significantly higher satisfaction with chiropractic care
compared with other conventional treatments.7,24
As with any other treatment, non-serious
side effects may occur following manipulation but they
are usually minor and short-lived. Such effects include
localized discomfort, headache, or fatigue resolving
within one to two days.19 Serious adverse events, such
as vertebrobasilar artery dissection associated with
cervical manipulation, are extremely rare. The rarity of
serious complications only allows for an estimation of
the potential risk. However, it is known that the risk
of serious complications following cervical manipulation
is significantly lower than the risk of other common
medical treatments for comparable conditions (i.e.
NSAIDs).26 Chiropractors are required to discuss risks
and obtain informed consent from patients prior to
treatment and they may modify treatment when other
predisposing risk factors exist. Government inquiries
have found chiropractic treatment to be safe and
effective and recommend its integration into the health
care system.27
Summary
As a result of their education and
training, chiropractors are well placed to treat spinal
and peripheral musculoskeletal disorders. The goal of
chiropractic treatment is to decrease pain and
disability and to restore function with the earliest
possible return to work and normal activity. Although
patient care is individualized based on patient
presentation, 50% of patients with chronic low back pain
that undergo chiropractic care report improvement by the
fourth visit or within two weeks, with 75% reporting
improvement by 12 weeks.28 This early recovery is also a
strong predictor of a continued positive outcome up to
one year later.29 Chiropractors are educated to diagnose
and identify indications and contraindications to
chiropractic therapy in the treatment of musculoskeletal
conditions. They are also educated to take and interpret
radiographs, when indicated, as part of the clinical
diagnostic process.5 If contraindications to treatment
are present, chiropractors are trained to identify red
flags and refer to the appropriate medical or health
care practitioner in a timely manner, or co-manage the
patient if appropriate. Medical doctors can be assured
that chiropractic care is safe, effective and
cost-effective and that chiropractors are well-trained
to manage musculoskeletal disorders, including the
delivery of multidisciplinary patient care.
This overview has been researched and
written by The Canadian Memorial Chiropractic College
(2005).
References
1. Woolf AD, Pfleger B. The Burden
of Major Musculoskeletal Conditions. Bulletin of
the World Health Organization, 2003; 81(9):
646-656.
2. Pinney SJ, Regan WD. Educating
medical students about musculoskeletal problems. The Journal of Bone and Joint Surgery (US)
2001;
83: 1317-1320.
3. Coyte PC, Asche CV, Croxford R,
Chan B. The economic cost of musculoskeletal
disorders in Canada. Arthritis Care Res. 1998; 11(5): 315-25.
4. Roux CH, Guillemin F, Boini S,
Longuetaud F, Arnault N, Hercberg S, Briancon S.
Impact of musculoskeletal disorders on quality of
life: an inception cohort study. Ann Rheum Dis.
2005; 64: 606-611.
5. Souza, TA. Differential Diagnosis
and Management for the Chiropractor: Protocols and
Algorithms, 2nd edition.
Maryland: Aspen Publishers Incorporation, 2001.
6. Cassidy DJ, Carroll LJ, Cote P.
The Saskatchewan Health and Back Pain Survey: The
Prevalence of Low Back Pain and Related Disability
in Saskatchewan Adults. Spine, 1998;
23(17):1860-1866.
7. Baldwin ML, Cote P, Frank JW,
Johnson WG. Cost-effectiveness studies of medical
and chiropractic care for occupational low back
pain: a critical review of the literature. The
Spine Journal. 2001; 1: 138-147.
8. Tveito TH, Hysing M, Eriksen HR.
Low back pain interventions at the workplace: a
systematic literature review. Occupational
Medicine. 2004; 54: 3-13.
9. Karjalainen K et al.
Multidisciplinary biopshychosocial rehabilitation
for subacute low back pain among working age adults.
The Cochrane Database of Systematic Reviews. 2001. Issue 3.
10. Hayden JA, van Tulder MW,
Tomlinson G. Systematic Review: Strategies for Using
Exercise Therapy to Improve Outcomes in Chronic Low
Back Pain. Ann Intern Med. 2005; 142:
776-785.
11. Cote P, Cassidy DJ, Carroll LJ,
Kristman V. The annual incidence and course of neck
pain in the general population: a population-based
cohort study. Pain. 2004; 112(3): 267-73.
12. Cote P, Cassidy DJ, Carroll LJ.
The Saskatchewan Health and Back Pain Survey: The
Prevalence of Neck Pain and Related Disability in
Saskatchewan Adults. Spine, 1998;
23(15):1689-1698.
13. Cote P, Cassidy DJ, Carroll LJ.
The Factors Associated with Neck Pain and Its
Related Disability in the Saskatchewan Population.
Spine, 2000; 25(9): 1109-1117.
14. Gross, A.R., Hoving, J.L.,
Haines, T.A., Goldsmith, C.H., Kay, T., Aker, P. &
Bronfort G. A Cochrane review of manipulation and
mobilization for mechanical neck disorders. Spine;
2004, 29(14): 1541-1548.
15. Conlin A, Bhogal S, Sequeira K,
Teasell R. Treatment of whiplash-associated
disorders, Part I: Non-invasive interventions. Pain Res Manag. 2005; 10(1): 21-32 Spitzer WO,
Skovron MK, Salmi RL, et al. Scientific monograph of
the Quebec Task Force on Whiplash Associated
Disorders: Redefining whiplash and its management.
Spine 20 (Supp 8) 1S-73S, 1995.
16. Korthals-de Bos et al. Cost
effectiveness of physiotherapy, manual therapy, and
general practitioner care for neck pain: economic
evaluation alongside a randomized controlled trial.
BMJ. 2003; 326: 1-6
17. Bronfort G, Assendelft WJJ,
Evans R, Haas M, Bouter L. Efficacy of Spinal
Manipulation for Chronic Headache: A Systematic
Review. J Manip Phyisio Ther. 2001; 24(7):
457-466.
18. Brooks PM. Impact of
osteoarthritis on individuals and society: how much
disability? Social consequences and health economic
implications. Curr Opin Rheum. 2002; 14:
573-577.
19. Meeker WC, Haldeman S.
Chiropractic: A Profession at the Crossroads of
Mainstream and Alternative Medicine. Academia and
Clinic. 2002:136(3): 216-227.
20. Assendelft W et al. Spinal
Manipulative Therapy for Low Back Pain. A
Meta-analysis of Effectiveness Relative to Other
Therapies. Ann Intern Med. 2003; 138:
871-881.
21. Evidence-Based Recommendations
for Medical Management of Chronic Non-malignant
Pain. Facilitated by the College of Physicians and
Surgeons of Ontario. November 2000.
22. UK Beam Trial Team. United
Kingdom back pain exercise and manipulation (UK
BEAM) randomized trial: cost-effectiveness of
physical treatments for back pain in primary care.
BMJ. 2004; doi=10.1136/bmj.38282.607859.AE
(published 29 November).
23. UK Beam Trial Team. United
Kingdom back pain exercise and manipulation (UK
BEAM) randomized trial: cost-effectiveness of
physical treatments for back pain in primary care.
BMJ. 2004; doi=10.1136/bmj.38282.669225.AE
(published 29 November).
24. Legoretta AP et al. Comparative
Analysis of Individuals With and Without
Chiropractic Coverage: Patient Characteristics,
Utilization and Costs. Arch Intern Med. 2004;
164: 1985-1992.
25. Workplace Safety & Insurance
Board of Ontario. Program of Care for Acute Low Back
Injuries: One-year Evaluation Report, June 2004;
www.chiropractic.on.ca/reschreport.htm
26. Dabbs V, Lauretti WJ. A Risk
Assessment of Cervical Manipulation vs. NSAIDs for
the Treatment of Neck Pain. J Manip Phyisio Ther.
1995; 18(10); 530-6.
27. Wells T et al. Chiropractic
Services Review. Ontario Ministry of Health, 1994.
28. Stig LC, Nilsson O, Leboeuf-Yde
C. Recovery Pattern of Patients Treated with
Chiropractic Spinal Manipulative Therapy for
Long-lasting or Recurrent Low Back Pain. J Manip
Phyisio Ther. 2001; 24(4): 288-291.
29. Leboeuf-Yde C et al. The Nordic
Back Pain Subpopulation Program: Demographic and
Clinical Predictors for Outcome in Patients
Receiving Chiropractic Treatment for Persistent Low
Back Pain. J Manip Phyisio Ther. 2004; 27(8):
493-502. |
