Implementation of Evidence-
Informed Physical Therapy and
Chiropractic Care Improves Value
To promote understanding of value in
spine care, the NASS Value Committee
presents the following invited article
as part of its ongoing Value series.
Other articles in the series are
Emily K. Karlen, MPT
Fairview Health Services
In any given year, one in five people will experience back pain so significant it will cause them to change how they do their daily activities.
1 About half of those people will seek
2, 3 Back pain creates a significant financial burden. The incremental costs to
manage back pain in the United States was reported at $86 billion.
3 This was more than
the cost of care for all cancers, diabetes and arthritis4 making back pain the sixth highest
contributor to the global burden of disease.
5 Costly care has not delivered better outcomes.
Recent studies found no improvement in self-assessed health status, functional disability,
work limitations or social function as a result of increased spine costs.
4, 6 Furthermore,
a recent AAOS report linked low back pain management to inefficient care and waste.
Although the rising prevalence and unit cost for spine surgery has greatly increased
the cost to manage spine patients, nonsurgical management costs also contributed
8, 9 The number of Americans seeking spine care grew from 10.8% to 13.5%
between 1997 and 2006, and the increased use of nonsurgical spine care, like MRIs and
injections, outpaced this growth.
3, 5, 6 In a commercially insured population of 14. 7 million, nonsurgical care represented 56% of all spine care spending, but included 97% of
all spine patients.
10 Despite individual nonsurgical back pain episodes averaging only
$1,056, the aggregate spine care cost for this population was over $6.4 billion.
10 From a
population health perspective, it is important to target high volume subpopulations which
impose a large collective cost to the whole population. Within our Minneapolis-based
health system, we learned our nonsurgical low back pain subpopulation mirrored Elton’s10
findings: 95% of our patients with low back pain were not receiving surgical care, but as
a subpopulation, accounted for 50% of the total spine cost. Given the equal financial
impact but the higher volume of people involved, we focused our improvement efforts
on the nonsurgical population.
Our health system aimed to improve the value of care for the spine population by
increasing quality outcomes and lowering cost. Since many of the treatments in best practice guidelines for patients with nonspecific low back pain can be delivered by physical
therapists (PTs) and chiropractors, we included both in our improvement efforts.
ancillary orthopedic clinics are largely staffed by PTs, but some clinics also employ chiropractors; the two disciplines have complemented and extended each others’ care for over
15 years in our system. Also, when clinicians deliver evidence-based care, more expensive
diagnostics and treatments like MRIs and injections decrease, ultimately resulting in better
functional outcomes and lower health care costs.15, 16 Evidence-based treatment for initial
presentation of nonspecific back pain includes education, reassurance, manipulation and
13, 14 These treatments consistently appear in guidelines from the United States