Posted on Apr 24, 2019
Collaboration for Low Back Pain Treatment in Older Adults
Part of the Evidence in Action series by Palmer College of Chiropractic
By Zacariah Shannon, DC, MS
The inclusion of chiropractic practitioners into various collaborative health systems has increased over the past decade, including:
- Onsite health clinics at large corporations such as Facebook and Google
- The US Department of Veterans Affairs
- Hospital systems
- Medical group settings
- Sports and Olympic teams.
The addition of chiropractic within these multi-disciplinary settings has been embraced by many as a way to manage spinal conditions, such as back and neck pain, using noninvasive therapies. However, taking a patient-centered approach to such integration involving various health care practitioners leads to new questions and challenges and requires novel research to optimize patient outcomes in these settings.
A recently published pilot study compared three models of professional practice on patient outcomes in older adults (65+ years) with low back pain.1 The three models were:
- medical care alone
- medical and chiropractic care
- and medical and chiropractic care with increased collaboration between MD and DC providers.
Collaboration included shared health history, treatment plans and progress notes. The chiropractic care was provided at the Palmer Center for Chiropractic Research located in Davenport, Iowa. The medical care was administered in a family medicine residency clinic associated with Genesis Health System, which is located within a 10 minute drive from the Palmer research center.
All three groups of participants were given 12 weeks of treatment. Medical care included a history, exam, self-care and exercise recommendations, medications and referrals to physical therapy or other health care providers, as necessary. Chiropractic care included spinal manipulation, mobilization, and/or instrument assisted manipulation applied to the full spine or extremities with emphasis on the low back. The main time point for comparison of outcomes was 12 weeks (at the end of treatment).
- Low back pain and disability – Clinically meaningful improvement in all groups with no significant difference between groups.
- Patient ratings of overall improvement, low back pain improvement, quality of life and satisfaction with health care services – Higher in groups that received chiropractic care.
This study did not evaluate a truly integrated health care delivery system, but rather two different systems working in close collaboration. It is unclear if similar results would be seen when chiropractic care is added to a multi-disciplinary model. Other limitations are with respect to treatment adherence disparity. Participants received free chiropractic care, but incurred out-of-pocket expenses for medical treatment or recommended treatments such as physical therapy. Due to this, some patients did not adhere to medical treatment suggestions.
Older adults are a unique, yet understudied population when it comes to low back pain.2 Ageist attitudes leading to the beliefs that back pain is inevitable at a certain age and that it is not an important concern relative to other comorbidities are common reasons given by older adults for not seeking care.3 The featured study showed that evidence-based care produced clinically meaningful improvement in low back pain and disability in older adults, regardless of health model. This may be reassuring for both patients and treating clinicians that improvement is possible for older adults. In addition, secondary outcomes of this study showed that older adults in this sample were more satisfied and perceived a greater level of improvement with the models that included chiropractic care.
Prior to beginning this clinical study, the research team conducted focus groups with older persons in the same community. They found that older adults not only preferred a complementary co-management approach to their care, but also had distinct preferences when it comes to what this co-management should entail,4stressing the need for good communication between their providers in regards to treatment plans, referrals and treatment notes being available across providers. These older adults were also concerned that lack of communication between co-managing providers could lead to redundant imaging and tests.
Whether a patient is being co-managed within the same clinic, such as a hospital setting, or between providers whom are located in separate practices, interdisciplinary communication is at the foundation of patient-centered care. Patients not only expect that medical doctors and chiropractors will have a cordial relationship, but also that they will be collaborative in their approach. Since a medical doctor is not likely to know the intricacies of different chiropractic techniques or the way in which they are applied, taking good notes that thoroughly explain the patient encounter, as well as putting the notes in language that other providers can understand, is essential. I believe that both the chiropractic profession and patients will benefit from this professional collaboration.
Dr. Shannon is a postdoctoral research scholar at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.