Medical vs chiropractic care

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There is some uncertainty about whether patients who go to a chiropractor are comparable to those who go to a physician (Carey et al 1995b, Nyiendo et al 1996, Hurwitz et al 1998, Cherkin et al 2002, Coulter et al 2002). Some studies suggest they may have less pain and disability, but others suggest they have about the same. Most patients who attend a chiropractor have recurrent pain and anything from 30 to 80% have seen a chiropractor before. Forty to 50% attend within 3 weeks of onset of their back pain, but 20-25% have had pain for more than 6 months. Carey et al (1995b) found that those seeking chiropractic care were in better general health, were more likely to have good health insurance, and had less severe pain. Coulter et al (2002) found that chiropractic patients had comparable levels of low back disability but poorer mental health.

Coulter et al (2002) also found that chiropractors and their patients share similar beliefs about health care. Saunders et al (1999), meantime, found that physician office visits were influenced by patient beliefs that pain required "medical" treatment and prescription analgesics. Such contrasting beliefs are likely to influence each patient's choice of care. Use of chiropractic varies most with region of the country and availability of practitioners. Cherkin et al (2002) found that 80% of chiropractic patients are young and middle-aged adults. Two-thirds are women. Whites are more likely to attend a DC or DO. The poorly educated are more likely to attend a family doctor (MD).

Hart et al (1995) and Shekelle et al (1995b) both gave information on average numbers of visits (Table 20.6). Family doctors (MDs) have the lowest number of return visits, while DOs and surgeons have more, and chiropractors have by far the highest number. Shekelle et al (1995b) also considered costs (Table 20.6). Health care costs per episode depend on the number of visits, cost per visit, drug costs, investigations, and hospitalization. Surgeons are by far the most expensive, mainly because of high-tech investigations, and hospitalization. Perhaps surprisingly, chiropractic care may not be cheaper than medical care. In Shekelle's study, low chiropractic cost per visit, low investigation costs, and lack of hospital costs were balanced by the large number of chiropractic visits per episode. However, some chiropractors dispute these figures, and argue they do not compare like with like.

Family practice and chiropractic should potentially be the cheapest and most cost-effective types of health care for an episode of non-specific low back pain. Most of the high costs of medical care are due to investigations and hospitalization, much of which may be unnecessary. If family practice could reduce these, it might be by far the cheapest. On the other hand, many chiropractic visits may be unnecessary. If chiropractic could control the number of visits per episode, it might be the cheapest.

Baldwin et al (2001) reviewed the evidence on the relative effectiveness and cost-effectiveness of medical and chiropractic care for back pain. There are now four randomized controlled trials (RCTs: Meade et al 1990, Cherkin et al 1998, Skargren et al 1998, Hurwitz et al 2002) and two cohort studies that show chiropractic and physiotherapy

Table 20.6 Number and relative costs of visits to each specialty in 1982


Mean number of



(relative to family





Family doctor














Based on data from Shekelle et al (1995a, b).

Based on data from Shekelle et al (1995a, b).

are equally effective in reducing symptoms and improving function. One RCT (Hurwitz et al 2002) and four cohort studies give conflicting evidence on the effectiveness of medical vs chiropractic care. Most studies find that chiropractic patients are more satisfied with their care. Baldwin et al (2001) found five cohort studies comparing costs and cost-effectiveness, but they all suffered methodologic problems. They concluded that, on the current evidence, it is not possible to say whether medical or chiropractic care is more cost-effective. (References to the cohort studies can be found in Baldwin et al 2001.)

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