By Adrian. Isaza BA Palmer College of Chiropractic Florida and Michael W. Shreeve, D.C. Professor Palmer College of Chiropractic Florida Campus
Total healthcare system spending on narcotic analgesics reached $8.3 billion in 2011.
Visiting a chiropractor as the first portal of entry Physician for pain as opposed to seeing an allopathic Physician first can reduce healthcare costs by reducing spending in narcotic analgesics.
This commentary also examines whether chiropractic treatment is safer than the most prescribed narcotic analgesic used in the treatment of pain including low back pain, knee pain, migraines, neck pain, shoulder pain, hand pain and hip pain.
Avoiding the adverse side effects associated with these pharmaceuticals may be a welcome side effect.
Key indexing terms: chiropractic, healthcare, costs.
According to the IMS institute for healthcare informatics, total healthcare spending on medicines Increased from 308.6$ billion in 2010 to 319.9$ billion in 2011. Patients with insurance paid 49$ billion out of pocket for retail Medicines and total spending on medicines on a real per capita basis, increased by 0.5%.
In 2006, back pain was the leading cause of disability in Americans under 45 years old. More than 26 million Americans between 20-64 experienced back pain (20). In 2007, nearly 28,000 Americans died from unintentional drug poisoning, and of these, nearly 12,000 involved prescription pain relievers (2).
In 2008, the cost to federal and state governments of medical expenditures for pain was 99 billion and 100 million Americans suffered from chronic pain (4). Also in 2008, prescription pain killer overdose killed close to 15,000 people in the US .This is more than 3 times the 4,000 people killed by these drugs in 1999. Nearly half a million emergency department visits in 2009 were due to people misusing or abusing prescription painkillers.
Nonmedical use of prescription painkillers costs health insurers up to 72.5 billion annually in direct healthcare costs (3).
In 2009, prescription drugs were the second most abused category of drugs in the United States, following marijuana (32).
Pain is a significant public health problem that costs society at least 560$-635$ billion annually (an amount equal to about 2,000$ for everyone living in the US (4). Recent center for disease control and prevention data suggests that causes of pain included LBP 28.1%, knee pain 19.5%, migraines 16.1%, neck pain 15.1%, shoulder pain 9.0%, finger pain 7.6% and hip pain 7.1% (5). In 2011, 15.6 million patients were treated for pain and hydrocodone was the most prescribed drug in the US (10).
This commentary will explore and evaluate whether visiting a Chiropractor as the first portal of entry for pain as opposed to seeing an allopathic doctor first can reduce healthcare costs by reducing spending on narcotic analgesics. This commentary will also examine whether chiropractic treatment is safer than the most prescribed narcotic analgesic used in the treatment of pain including low back pain, knee pain, migraines, neck pain, shoulder pain hand pain and hip pain.
This could reduce spending on pharmaceuticals for patients who pay out of pocket as well as reduce spending by third party payers while minimizing the adverse side effects associated with these pharmaceuticals.
All citations were from 1987 to 2014. The search only used published documents including Books and peer reviewed articles in this commentary. Case studies were excluded.
The most prescribed pharmaceutical used in the treatment pain was evaluated for adverse effects and compared to chiropractic adjustments to determine which was safer.
Reimbursements for both allopathic doctors and chiropractors per visit were compared to determine which type of provider would maximize savings. Finally, research supporting chiropractic cost effectiveness, the economic burden associated with narcotic analgesics and positive outcomes using chiropractic treatment was provided.
Comparison of reimbursements for allopathic doctors and Chiropractors per visit resulted in an average saving of $14 per visit for new patients when visiting a chiropractor as opposed to visiting an allopathic doctor. Through examination of safety, hydrocodone wasn’t recommended for children of any age while chiropractic is practiced safely in children as demonstrated with the research associated with the treatment of low back pain in children. Furthermore, the evidence indicates that chiropractic has benign adverse effects with a very low incidence of adverse effects as opposed to the adverse effects with hydrocodone which is associated with central nervous system and respiratory depression, lightheadedness, GI upset, constipation, urinary retention, rash and hepatotoxicity.
Finally, there are peer reviewed publications suggesting that Chiropractic adjustments are efficient and more cost effective when treating pain compared to allopathic doctors.
The evidence suggests that chiropractic treatment is less expensive than allopathic treatment regarding average reimbursement fees for new patients and it is more cost effective than allopathic treatment for the treatment of spinal pain. Chiropractic can help maximize savings by treating low back pain, knee pain, migraines, neck pain, shoulder pain, hand and hip pain by reducing the intake of prescribed narcotic analgesics and consequently, it may reduce the economic burden associated with it.
Furthermore, chiropractic is safer than narcotic analgesics since it has relatively benign side effects compared to the side effects associated with hydrocodone and all other narcotic analgesics.
Chiropractic should be considered in the treatment of low back pain, knee pain, migraines, neck pain, shoulder pain, hand and hip pain in order to maximize savings and avoid the adverse side effects of narcotic analgesics.
Table 1: Adverse effects and contraindications of chiropractic and hydrocodone (11)(12) (13)(15) (16)(17) (18)
(most prescribed drug in the US in 2011 with $8.3 billion in spending and 15.6 million patients treated (10)
CNS/respiratory depression, lightheadedness, GI upset, constipation, urinary retention, rash; hepatotoxicity. NOTE: The risk of acute liver is higher in individuals with underlying liver disease and in individuals who ingest alcohol while taking acetaminophen.
Children: Not recommended
A study retrieving numerous studies from 1966 to 2007 indicated that most adverse events that could be attributed to
Spinal manipulation was benign and transitory.
A study of 818 patients with vertebra basilar artery strokes between 1993 and 2002 found no evidence of excess risk of VBA strokes associated Chiropractic care compared to primary care.
Of the estimated several hundred million manipulative treatments performed each year, only 185 reports of injury were found in the published literature from 1925 to 1993.
Another study reviewing literature from 1966 to 1994 indicated that cervical manipulation for neck pain was much safer than NSAIDS by as much as a factor of several hundred
A cohort study revealed that 54 young patients between 4 and 18 years old receiving
chiropractic care for back pain showed distinct improvements in both a subjective scale and a pain questionnaire
Table 2: Reimbursement comparison of new patients per visit between chiropractic and allopathic doctors in 2013 (19)
CPT PROCEDURE CODE FOR PATIENT VISIT
SAVINGS IN DOLLARS PER VISIT
Note: Only 12% of Chiropractors have a cash based practice with an average fee of 60$ per visit
New patient E/M
New patient E/M
New patient E/M
New patient E/M
14 dollars per visit
15.6 million patients were treated for pain in 2011 (10). If 50% of these patients visited a Chiropractor instead of an allopathic doctor:
Savings=7.8 million patients x 14$ (savings per 1 visit) = 109.2 million dollars in savings if 50% of these patients treated for pain visited a chiropractor instead of an allopathic doctor.
Table 3: Evidence of chiropractic cost effectiveness in chronological order
This retrospective study of Florida workers’ compensation claims from 1994-1999 found that the average total cost for low-back cases treated medically was $16,998 while chiropractic care was only $7,309. Patients treated primarily by chiropractors were found to reach maximum medical improvement almost 28 days sooner that if treated medically. Findings from this analysis of the Florida Claims and medical files indicate that considerable cost savings and more efficient claims resolution may be possible with greater involvement of chiropractic treatment in specific low back cases and other specific musculoskeletal cases
A 4-year retrospective review of claims from 1.7 million health plan members analyzed the cost effects of having a chiropractic benefit in their HMO insurance plan. The data revealed that members with the chiropractic benefit had lower overall total annual health care costs. Back pain patients with chiropractic coverage also realized lower utilization of plain radiographs, low back surgery, hospitalizations and MRI’s. Back pain episode-related costs were also 25 percent lower for those with chiropractic coverage ($289 vs. $399).
In a 4-year study period, the claims of 8 million members insured by a managed health plan were evaluated to determine how patients utilize chiropractic treatment when they have a chiropractic benefit. They found that patients use chiropractic as a direct substitution for medical care, choosing chiropractic 34 percent of the time. Having a chiropractic benefit rider did not increase the number of patients seeking care for neuro-musculoskeletal complaints
A retrospective review of 96,627 claims between 1975 and 1994 found that the average cost of treatment, hospitalization, and compensation payments were higher for patients treated by MDs than for patients treated by DCs. Average number of lost workdays for patients treated by MDs was higher than for those treated by DCs. Combined care patients generated higher costs than patients treated by MDs or DCs alone.
During the 4-year study, this integrative medical approach, emphasizing a variety of Alternative Medical) therapies, realized lower patient costs and improved clinical outcomes for patients. The patients who used DCs as their primary care providers had 43 percent decreases in hospital admissions, 52 percent reductions in pharmaceutical costs and 43 percent less outpatient surgeries and procedures
Chiropractic care is more effective than other modalities for treating low back and neck pain. For low back pain, chiropractic physician care increases total annual per patient spending by $75 compared to medical physician care. For neck pain, chiropractic physician care reduces total annual per patient spending by $302 compared to medical physician care. When considering effectiveness and cost together, chiropractic physician care for low back and neck pain is highly cost-effective, [and] represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.
Note: Spending on pharmaceuticals wasn’t accounted for.
Table 4: Evidence of the economic burden associated with narcotic analgesics
Patients with LBP who had surgery were significantly more likely to use narcotic drugs within 1 week of procedure than those patients without surgery. In contrast, patients with LBP who had chiropractic services for LBP were less likely to take narcotic drugs within 7 days after services compared to those without chiropractic services. Furthermore, controlling for health conditions, patients with LBP who took narcotic medications were significantly more likely than patients not taking narcotics to have an emergency room visit within 30 days after the initial narcotic drug prescription dates. Narcotic-using patients with LBP accounted for 62% of health care costs among all patients with LBP. The average monthly health care cost for a narcotic-using LBP patient was $1222, compared to $430 for a LBP patient not using narcotic drugs. The subjects with LBP who used narcotic medications were more likely to have additional coexisting health conditions and used more health care services than non-using patients with LBP. Unadjusted health care services costs, including pharmacy claims costs, were significantly higher in patients with LBP using narcotic drugs than in non-using patients with LBP.
In 2006, approximately 5.2 million individuals in the United States reported using prescription analgesics non-medically in the prior month, up from 4.7 million in 2005. The total cost of prescription opioid abuse in 2001 was estimated at $8.6 billion, including workplace, health care, and criminal justice expenditures. One study of commercially insured beneficiaries in the United States found that mean per-capita annual direct health care costs from 1998 to 2002 were nearly $16,000 for abusers of prescription and nonprescription opioids compared with approximately $1,800 for non-abusers who had at least 1 prescription insurance claim.
Total US societal costs of prescription opioid abuse were estimated at $55.7 billion in 2007 (USD in 2009). Workplace costs accounted for $25.6 billion (46%), health care costs accounted for $25.0 billion (45%), and criminal justice costs accounted for $5.1 billion (9%). Workplace costs were driven by lost earnings from premature death ($11.2 billion) and reduced compensation/lost employment ($7.9 billion). Health care costs consisted primarily of excess medical and prescription costs ($23.7 billion). Criminal justice costs were largely comprised of correctional facility ($2.3 billion) and police costs ($1.5 billion). The costs of prescription opioid abuse represent a substantial and growing economic burden for the society. The increasing prevalence of abuse suggests an even greater societal burden in the future.
In 2006, the estimated total cost in the United States of nonmedical use of prescription opioids was $53.4 billion, of which $42 billion (79%) was attributable to lost productivity, $8.2 billion (15%) to criminal justice costs, $2.2 billion (4%) to drug abuse treatment, and $944 million to medical complications (2%). Five drugs–OxyContin, oxycodone, hydrocodone, propoxyphene, and methadone–accounted for two-thirds of the total economic burden.
Table 5: Evidence of positive treatment outcome of chiropractic for selected conditions, Part 1
LOWER BACK PAIN 28.1%
In a 1995 study of 741 men and women aged 18-64 years with low back pain it was found that when chiropractic or hospital therapists treat patients with low back pain those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.
A study in the year 2000 of 93 chiropractic patients and 45 medical patients with chronic, recurrent low-back pain found that patients with chronic low-back pain treated by chiropractors show greater improvement and satisfaction at 1 month than patients treated by family physicians
A 2003 study randomly allocated 115 patients with chronic back and neck pain to receive medication ( non-steroidal anti-inflammatory drugs), needle acupuncture, or chiropractic spinal manipulation. At the end of nine weeks of treatment those who received chiropractic spinal manipulation displayed the best improvements in disability, range of motion, and pain scores.
A 2004 study involving 2,870 patients with acute and chronic low back pain who visited either medical or chiropractic physicians’ offices yielded clinically important advantages in decreasing both pain and disability scores for those treated by chiropractors. Most improvement was seen by 3 months and sustained by 1 year.
A 2004 study using two groups: One had a chiropractic adjustment every three weeks beyond the 12 treatments given within the first month to both groups. The group receiving the supplementary maintenance treatments continued to display reductions in disability, while the cohort lacking the additional visits reverted to baseline levels.
A 2006 randomized controlled trial of 102 patients concluded that
Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.
In 2007 a systematic review to help the American Pain Society and the American College of Physicians prepare a clinical practice guideline; they concluded that spinal manipulation was the most effective non-pharmacological treatment for acute and chronic low back pain.
Table 6: Evidence of positive treatment outcome of chiropractic for selected conditions, Part 2
A randomized controlled trial in the year 2000 of 28 patients suggested that SI-joint manipulation reduces knee-extensor muscle inhibition.
Spinal manipulation may possibly be an effective treatment of muscle inhibition in the lower limb musculature
A 2008 study of 43 patients with osteoarthritis knee pain determined that a short-term manual therapy knee protocol significantly reduced pain suffered by participants with osteoarthritis knee pain and resulted in improvements in self-reported knee function immediately after the end of the 2 week treatment period.
A 2009 systematic review concluded that there is a level of B or fair evidence for manipulative therapy of the knee.
A 2009 study of 21 patients found that manipulation under anesthesia has a role in the treatment of early stiffness with excellent immediate outcomes. MUA should be the first line of management for stiff knee arthroplasties after failed physiotherapy
A 1998 study of 218 patients concluded that spinal manipulation seemed to be as effective as a well-established and efficacious treatment (amitryptylin) after 8 weeks.
A study in the year 2000 involving 127 patients supported previous results showing that some people report significant improvement in migraines after chiropractic spinal manipulative therapy after 2 months.
A 2001 systematic review concluded spinal manipulative therapy appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for migraine headache
A 2011 systematic review concluded that current RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally efficient as propranolol and topiramate in the prophylactic management of migraine.
A 2011 study of 21 articles found that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches.
Table 7: Evidence of positive treatment outcome of chiropractic for selected conditions, Part 3
A 1992 randomized controlled trial of 100 patients concluded that a single manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain. Both treatments increase range of motion in the neck to a similar degree
A 2002 systematic review found that the patients with neck pain who received manual therapy reported marked advantages over the groups given physical therapy or care by general practitioners.
A 2006 randomized controlled trial of 70 patients determined that a
Single cervical high velocity low amplitude manipulation was more effective in reducing neck pain at rest and in increasing active cervical range of motion than a mobilization procedure in subjects with mechanical neck pain.
A 2008 study involving 19,722 patients found that predictor variables
For immediate and global responses to chiropractic manipulation of the cervical spine were strongest for immediate improvement
A 2009 review of the scientific literature published between 1980 and 2006. recommended that most patients with neck pain would benefit from manual therapies ( mobilization, manipulation, and massage),
A 2004 clinical trial of 150 patients concerning the shoulder girdle that compared usual medical care both with and without high-velocity low-amplitude manipulations revealed that spinal manipulation accelerated the recovery from shoulder symptoms
A 2011 systematic study found a level of B or fair evidence for manual manipulative therapy of the shoulder, shoulder girdle combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction.
A 2012 study of 50 patients with frozen shoulder determined that most patients with frozen shoulder syndrome in that case series appeared to improve with the chiropractic treatment.
Table 8: Evidence of positive treatment outcome of chiropractic for selected conditions, Part 4
A 1993 study of 22 patients indicated that carpal tunnel syndrome subjects can be treated and achieve a significant recovery to within normal comparative levels of non-CTS subjects in most subjective and objective measures.
A randomized control trial in 1998 of 91 patients concluded that Carpal tunnel syndrome associated with median nerve demyelination but not axonal degeneration may be treated with commonly used components of conservative medical or chiropractic care.
A systematic review in 1998 of more than 200 articles published in the health care literature from 1963 to 1997 concluded that carpal tunnel syndrome, accompanied by demyelination but without axonal degeneration, can be treated initially with conservative medical or manual procedures.
A 2007 study of 47 patients provided strong self-reported, albeit preliminary, evidence of benefit for chiropractic treatment of hand and wrist pain.
A study of 52 patients in 1998 suggested that manual therapy of the neck may affect hip range of motion in normal adults.
A study of 17 patients in 2008 found that chiropractic treatment can improve hip extensibility in subjects with restriction as measured by the modified Thomas test
A study of 14 patients in 2010 concluded that Chiropractic care may provide a short-term benefit in decreasing hip pain for patients with hip osteoarthritis waiting for hip arthroplasty.
A systematic review in 2012 of over 399 citations concluded that there is a there is a level of B (fair evidence) for short-term treatment of hip osteoarthritis
Table 9: Possible dietary supplements used as adjunct therapy (1) (47) (48)(49)
Glucosamine sulfate and chondrotin
Mechanism of action
Universal methyl donor
200-800 mg bid
Glucosamine 500mg three times daily; chondroitin 400mg three times daily
Level of evidence
Interaction side effects
None, may precipitate mania in bipolar disorders
None reported; rare reports of constipation, diarrhea, drowsiness
Insulin resistance not seen in clinical trials
Studies comparing with drugs
In a double-blind study, the efficacy and tolerability of S-adenosylmethionine (SAMe) were evaluated in comparison with those of placebo and naproxen in the treatment of osteoarthritis of the hip, knee, spine, and hand. SAMe administered orally at a dose of 1,200 mg daily was shown to exert the same analgesic activity as naproxen at a dose of 750 mg daily. Tolerability of SAMe was significantly better than that of naproxen, both in terms of physicians’ and patients’ judgments and in terms of the number of patients with side effects.
A 2004 study determined that SAM-e has a slower onset of action but is as effective as celecoxib in the management of symptoms of knee osteoarthritis.
A 2007 study indicated that glucosamine sulfate at the oral once-daily dosage of 1,500 mg is more effective than placebo in treating knee OA symptoms. Although acetaminophen also had a higher responder rate compared with placebo, it failed to show significant effects on the algo functional indexes.
This commentary poses a very important decision to make as a society: Do we desperately look for flaws in the available research in order to sell more pain medication that is causing harm to thousands of people or do we embrace a safer and more cost effective form of medicine through chiropractic?
When evaluating cost for pain the $8.3 billion spent on narcotic analgesics in 2011 isn’t the only consideration. Health insurance costs for visits to allopathic doctors and emergency department visits must be accounted for.
When evaluating safety, the adverse effects with hydrocodone which includes central nervous system and respiratory depression, lightheadedness, GI upset, constipation, urinary retention, rash and hepatotoxicity isn’t the only consideration. Drug poisoning, overdose, addiction, deaths and emergency department visits must be accounted for.
Besides cost and safety we are faced with a medical question: Is taking narcotic analgesics treating a symptom of pain or is it actually treating the cause of the symptom of pain? It seems evident that narcotic analgesics only treats the symptom and does nothing to treat the cause, therefore from a medical and scientific point of view, chiropractic’s superior efficiency is due to the chiropractic approach to pain which is to find the cause of pain and remove it through manipulation.
The adjunctive therapy in the form of nutritional supplements was mentioned in this commentary as a possible second line of treatment for the conditions listed but the adjunctive therapy isn’t limited to nutritional supplementation. As an example, if a patient has osteoarthritis in the lower back, cervical spine, hip or hand which is causing pain, the Chiropractic Physician could consider supplementation with SAM-e in addition to the chiropractic adjustment. If the patient has knee osteoarthritis the Chiropractic Physician could consider supplementation with glucosamine/chondroitin or SAM-e in addition to the Chiropractic adjustment.
1. McPhee, S. J., & Papadakis, M. A. (Eds.). (2007). Current medical diagnosis & treatment 2010. McGraw-Hill Medical.
2. Unintentional Drug Poisoning in the United States, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, July 2010.
3. Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008, Centers for Disease Control and Prevention Analysis: Morbidity and Mortality Weekly Report (MMWR), November 4, 2011 / 60(43);1487-1492.
4. Institute of Medicine of the National Academies Report. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, 2011. The National Academies Press, Washington DC. (page 5)
5. Institute of Medicine of the National Academies Report. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, 2011. The National Academies Press, Washington DC. (page 62)
6. Hansen, R. N., Oster, G., Edelsberg, J., Woody, G. E., & Sullivan, S. D. (2011). Economic costs of nonmedical use of prescription opioids. The Clinical journal of pain, 27(3), 194-202.
7.Smith, C., Crowther, C., & Beilby, J. (2002). Pregnancy outcome following women’s participation in a randomised controlled trial of acupuncture to treat nausea and vomiting in early pregnancy. Complementary therapies in Medicine, 10(2), 78-83.
8. Suter, E., McMorland, G., Herzog, W., & Bray, R. (2000). Conservative lower back treatment reduces inhibition in knee-extensor muscles: a randomized controlled trial. Journal of manipulative and physiological therapeutics, 23(2), 76-80.
9. Phelan, S. P., Armstrong, R. C., Knox, D. G., Hubka, M. J., & Ainbinder, D. A. (2004). An evaluation of medical and chiropractic provider utilization and costs: treating injured workers in North Carolina. Journal of manipulative and physiological therapeutics, 27(7), 442-448.
10. IMS Institute for Healthcare Informatics. (2011). The use of medicines in the united states: Review of 2011.
11. Physician desk reference 2014
12. Monthly prescribing reference 2009
13. Gouveia, L. O., Castanho, P., & Ferreira, J. J. (2009). Safety of chiropractic interventions: a systematic review. Spine, 34(11), E405-E413.
14. Cassidy, J. D., Lopes, A. A., & Yong-Hing, K. (1992). The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: a randomized controlled trial. Journal of Manipulative and Physiological Therapeutics, 15(9), 570.
15. Cassidy, J. D., Boyle, E., Côté, P., He, Y., Hogg-Johnson, S., Silver, F. L., & Bondy, S. J. (2009). Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Journal of manipulative and physiological therapeutics, 32(2), S201-S208.
16. Vick, D. A., McKay, C., & Zengerle, C. R. (1996). The safety of manipulative treatment: review of the literature from 1925 to 1993. JAOA: Journal of the American Osteopathic Association, 96(2), 113-113.
17. Dabbs, V., & Lauretti, W. J. (1995). A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics, 18(8), 530-536.
18. Hayden, J. A., Mior, S. A., & Verhoef, M. J. (2003). Evaluation of chiropractic management of pediatric patients with low back pain: a prospective cohort study. Journal of manipulative and physiological therapeutics, 26(1), 1-8.
19. Chiropractic Economics. October 11, 2013
20. National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain.
21. Giles, L. G., & Muller, R. (2003). Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine, 28(14), 1490-1502.
22. Haas, M., Goldberg, B., Aickin, M., Ganger, B., & Attwood, M. (2004). A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up. Journal of manipulative and physiological therapeutics, 27(3), 160-169.
23. Pollard, H., Ward, G., Hoskins, W., & Hardy, K. (2008). The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial. The Journal of the Canadian Chiropractic Association, 52(4), 229.
24. Martin, B. I., Deyo, R. A., Mirza, S. K., Turner, J. A., Comstock, B. A., Hollingworth, W., & Sullivan, S. D. (2008). Expenditures and health status among adults with back and neck problems. Jama, 299(6), 656-664.
25. Nelson, C. F., Bronfort, G., Evans, R., Boline, P., Goldsmith, C., & Anderson, A. V. (1998). The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of manipulative and physiological therapeutics, 21(8), 511-519.
26. Tuchin, P. J., Pollard, H., & Bonello, R. (2000). A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. Journal of manipulative and physiological therapeutics, 23(2), 91-95.
27. Santilli, V., Beghi, E., & Finucci, S. (2006). Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal, 6(2), 131-137.
28. Chou, R., & Huffman, L. H. (2007). Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of internal medicine, 147(7), 492-504.
29. Gross, A. R., Kay, T., Hondras, M., Goldsmith, C., Haines, T., Peloso, P., … & Hoving, J. (2002). Manual therapy for mechanical neck disorders: a systematic review. Manual Therapy, 7(3), 131-149.
30. Bryans, R., Descarreaux, M., Duranleau, M., Marcoux, H., Potter, B., Ruegg, R., … & White, E. (2011). Evidence-based guidelines for the chiropractic treatment of adults with headache. Journal of manipulative and physiological therapeutics, 34(5), 274-289.
31. Brantingham, J. W., Globe, G., Pollard, H., Hicks, M., Korporaal, C., & Hoskins, W. (2009). Manipulative therapy for lower extremity conditions: expansion of literature review. Journal of manipulative and physiological therapeutics, 32(1), 53-71.
32. Results from the 2009 National Survey on Drug Use and Health (NSDUH): National Findings, SAMHSA (2010)
33. Chaibi, A., Tuchin, P. J., & Russell, M. B. (2011). Manual therapies for migraine: a systematic review. The journal of headache and pain, 12(2), 127-133.
34. Bergman, G. J., Winters, J. C., Groenier, K. H., Pool, J. J., Meyboom-de Jong, B., Postema, K., & Van Der Heijden, G. J. (2004). Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and paina randomized, controlled trial. Annals of Internal Medicine, 141(6), 432-439.
35. Brantingham, J. W., Cassa, T. K., Bonnefin, D., Jensen, M., Globe, G., Hicks, M., & Korporaal, C. (2011). Manipulative therapy for shoulder pain and disorders: expansion of a systematic review. Journal of manipulative and physiological therapeutics, 34(5), 314-346.
36. Bronfort, G., Assendelft, W. J., Evans, R., Haas, M., & Bouter, L. (2001). Efficacy of spinal manipulation for chronic headache: a systematic review. Journal of manipulative and physiological therapeutics, 24(7), 457-466.
37. Hurwitz, E. L., Carragee, E. J., van der Velde, G., Carroll, L. J., Nordin, M., Guzman, J., … & Haldeman, S. (2009). Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics, 32(2), S141-S175.
38. Folsom, B. L., & Holloway, R. W. (2002). Chiropractic Care of Florida Workers’ Compensation Claimants: Access, Costs, and Administrative Outcome Trends from 1994 to 1999. Topics in Clinical Chiropractic, 9, 33-53.
39. Sarnat, R. L., Winterstein, J., & Cambron, J. A. (2007). Clinical utilization and cost outcomes from an integrative medicine independent physician association: an additional 3-year update. Journal of manipulative and physiological therapeutics, 30(4), 263-269.
40. Legorreta, A. P., Metz, R. D., Nelson, C. F., Ray, S., Chernicoff, H. O., & DiNubile, N. A. (2004). Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Archives of Internal Medicine, 164(18), 1985-1992.
41. Metz, R. D., Nelson, C. F., LaBrot, T., & Pelletier, K. R. (2004). Chiropractic care: is it substitution care or add-on care in corporate medical plans?. Journal of occupational and environmental medicine, 46(8), 847-855.
42. Mohammed, R., Syed, S., & Ahmed, N. (2009). Manipulation under anaesthesia for stiffness following knee arthroplasty. Annals of the Royal College of Surgeons of England, 91(3), 220.
43. Choudhry, N., & Milstein, A. (2009). Do Chiropractic Physician Services for Treatment of Low Back and Neck Pain Improve the Value of Health Benefit Plans?. Foundation for Chiropractic Progress.
44. Descarreaux, M., Blouin, J. S., Drolet, M., Papadimitriou, S., & Teasdale, N. (2004). Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. Journal of manipulative and physiological therapeutics, 27(8), 509-514.
45. Nyiendo, J., Haas, M., & Goodwin, P. (2000). Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: a practice-based feasibility study. Journal of manipulative and physiological therapeutics, 23(4), 239-245.
46. Martínez-Segura, R., Fernández-de-las-Peñas, C., Ruiz-Sáez, M., López-Jiménez, C., & Rodríguez-Blanco, C. (2006). Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial. Journal of manipulative and physiological therapeutics, 29(7), 511-517.
47. Caruso, I., & Pietrogrande, V. (1987). Italian double-blind multicenter study comparing S-adenosylmethionine, naproxen, and placebo in the treatment of degenerative joint disease. The American journal of medicine, 83(5), 66-71.
48. Herrero?Beaumont, G., Ivorra, J. A. R., del Carmen Trabado, M., Blanco, F. J., Benito, P., Martín?Mola, E., … & Branco, J. (2007). Glucosamine sulfate in the treatment of knee osteoarthritis symptoms: A randomized, double?blind, placebo?controlled study using acetaminophen as a side comparator. Arthritis & rheumatism, 56(2), 555-567.
49. Najm, W. I., Reinsch, S., Hoehler, F., Tobis, J. S., & Harvey, P. W. (2004). S-adenosyl methionine (SAMe) versus celecoxib for the treatment of osteoarthritis symptoms: a double-blind cross-over trial.[ISRCTN36233495]. BMC musculoskeletal disorders, 5(1), 6.
50. Thiel, H. W., & Bolton, J. E. (2008). Predictors for immediate and global responses to chiropractic manipulation of the cervical spine. Journal of manipulative and physiological therapeutics, 31(3), 172-183.
51. Murphy, F. X., Hall, M. W., D’Amico, L., & Jensen, A. M. (2012). Chiropractic management of frozen shoulder syndrome using a novel technique: a retrospective case series of 50 patients. Journal of chiropractic medicine, 11(4), 267-272.
52. Davis, P. T., Hulbert, J. R., Kassak, K. M., & Meyer, J. J. (1998). Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trail. Journal of manipulative and physiological therapeutics, 21(5), 317.
53. Davis, P. T., & Hulbert, J. R. (1998). Carpal tunnel syndrome: conservative and nonconservative treatment. A chiropractic physician’s perspective. Journal of manipulative and physiological therapeutics, 21(5), 356-362.
54. Bonebrake, A. R., Fernandez, J. E., Dahalan, J. B., & Marley, R. J. (1992). A treatment for carpal tunnel syndrome: results of a follow-up study. Journal of manipulative and physiological therapeutics, 16(3), 125-139.
55. Hulbert, J. R., Osterbauer, P., Davis, P. T., Printon, R., Goessl, C., & Strom, N. (2007). Chiropractic treatment of hand and wrist pain in older people: systematic protocol development: Part 2: cohort natural-history treatment trial.Journal of chiropractic medicine, 6(1), 32-41.
56.Pollard, H., & Ward, G. (1997). The effect of upper cervical or sacroiliac manipulation on hip flexion range of motion. Journal of manipulative and physiological therapeutics, 21(9), 611-616.
57.Sandell, J., Palmgren, P. J., & Björndahl, L. (2008). Effect of chiropractic treatment on hip extension ability and running velocity among young male running athletes. Journal of chiropractic medicine, 7(2), 39-47.
58. Thorman, P., Dixner, A., & Sundberg, T. (2010). Effects of chiropractic care on pain and function in patients with hip osteoarthritis waiting for arthroplasty: a clinical pilot trial. Journal of manipulative and physiological therapeutics, 33(6), 438-444.
59. Brantingham, J. W., Bonnefin, D., Perle, S. M., Cassa, T. K., Globe, G., Pribicevic, M., … & Korporaal, C. (2012). Manipulative therapy for lower extremity conditions: update of a literature review. Journal of manipulative and physiological therapeutics, 35(2), 127-166.
60. Rhee, Y., Taitel, M. S., Walker, D. R., & Lau, D. T. (2007). Narcotic drug use among patients with lower back pain in employer health plans: a retrospective analysis of risk factors and health care services. Clinical therapeutics, 29(11), 2603-2612.
61. Strassels, S. A. (2009). Economic burden of prescription opioid misuse and abuse. Journal of managed care pharmacy: JMCP, 15(7), 556-562.
62. Birnbaum, H. G., White, A. G., Schiller, M., Waldman, T., Cleveland, J. M., & Roland, C. L. (2011). Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine, 12(4), 657-667.
63. Meade, T. W., Dyer, S., Browne, W., & Frank, A. O. (1995). Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. Bmj, 311(7001), 349-351.