Concern about improper payments to chiropractic physicians prompted the US Department of Health and Human Services to describe chiropractic services as a “significant vulnerability” for Medicare, but little is known about trends in the use and cost of chiropractic spinal manipulation provided under Medicare.
To quantify the volume and cost of chiropractic spinal manipulation services for older adults under Medicare Part B and identify longitudinal trends.
Serial cross-sectional design for retrospective analysis of administrative data.
Annualized nationally representative samples of 5.0 to 5.4 million beneficiaries.
Chiropractic users, allowed services, allowed charges, and payments.
Descriptive statistics were generated by analysis of Medicare administrative data on chiropractic spinal manipulation provided in the United States from 2002 to 2008. A 20% nationally representative sample of allowed Medicare Part B fee-for-service claims was merged, based on beneficiary identifier, with patient demographic data. The data sample was restricted to adults aged 65 to 99 years, and duplicate claims were excluded. Annualized estimates of outcome measures were extrapolated, per beneficiary and per user rates were estimated, and volumes were stratified by current procedural terminology code.
The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.
Chiropractic claims account for less than 1/10th of 1% of overall Medicare expenditures. Allowed services, allowed charges, and fee-for-service payments for chiropractic spinal manipulation under Medicare Part B generally increased from 2002, peaked in 2005 and 2006, and then declined through 2008. Per user spending for chiropractic spinal manipulation also declined by 18% from 2006 to 2008, in contrast to 10% growth in total spending per beneficiary and 16% growth in overall Medicare spending.
Chiropractic; Medicare; Aged; Use
The multiplicity of bio-psychosocial and economic facets of chronic disabling back and/or neck pain complicates treatment outcomes measurement. Our previous work showed that personal functional goal achievement contributed more toward patient satisfaction with outcome than did traditional self-reports of pain and physical function or measured strength, flexibility and endurance among functional restoration program (FRP) graduates with chronic disabling back and/or neck pain.
The primary goal was to compare the impact on patient satisfaction of pain and functional goal achievement versus self-reports of pain and physical function.
This was an observational study of all patients with chronic disabling back and/or neck pain completing an FRP between 6/08 and 5/09.
Prior to treatment, participants recorded personal 3-month goals for: pain, work, recreation and activities of daily living. At least 3 months later, all graduates were sent a follow-up survey displaying the patient’s pretreatment functional goals and eliciting the patient’s assessment of functional goal achievement; current pain magnitude, “satisfaction with the overall results for your pain problem;” and responses to the SF-36v2 Physical Functioning subscale (PF-10).
Pain goal achievement was calculated as the difference between the pre-treatment pain goal and follow-up pain magnitude. Linear regression was used to evaluate the associations between satisfaction and four variables (follow-up pain; PF-10; pain goal achievement; function goal achievement), individually and then together in a full model.
Of the 82 patients surveyed, 62 responded completely. Mean age was 44 years, with 48% female and 35% on worker’s compensation. The model R2 combining all four variables explained 0.6033 of the variance in satisfaction. Each variable by itself was significantly related to patient satisfaction at p < .001, but the overlap in association was large. The unique contributions (R2) to the variation in satisfaction were: function goal achievement: 0.0471; PF-10 score: 0.0229; pain magnitude: 0.0178; and pain goal achievement: 0.0020.
At least 3 months after treatment, function goal achievement had by far the greatest impact on patient satisfaction, followed by PF-10 score, pain magnitude, and finally, pain goal achievement. Functional goal achievement has great potential as a tool for patient-centered treatment decision-making and outcomes measurement for people with chronic disabling back and/or neck pain and their health care providers.
goal achievement; functional restoration; rehabilitation; chronic low back pain; patient satisfaction
Astronauts experience back pain, particularly low back pain, during and after spaceflight. Recent studies have described histological and biochemical changes in rat intervertebral discs after space travel, but there is still no in vitro model to investigate the effects of microgravity on disc metabolism.
To study the effects of microgravity on disc degeneration and to establish an in vitro simulated microgravity study model
Discs were cultured in static and rotating conditions in bioreactor, and the characteristics of disc degeneration were evaluated
The mice discs were cultured in a rotating wall vessel bioreactor where the microgravity condition was simulated. Intervertebral discs were cultured in static and microgravity condition. Histology, biochemistry, and immunohistochemical assays were performed to evaluate the characteristics of the discs in microgravity condition.
Intervertebral discs cultured in rotating bioreactors were found to develop changes of disc degeneration manifested by reduced red Safranin-o staining within the annulus fibrosus, downregulated GAG content and GAG/Hypro ratio, increased MMP-3 expression, and upregulated apoptosis.
We conclude that simulated microgravity induces the molecular changes of disc degeneration. The rotating bioreactor model will provide a foundation to investigate the effects of microgravity on disc metabolism.
intervertebral disc; microgravity; disc degeneration; apoptosis; extracellular matrix
Degeneration and injuries of the intervertebral disc result in large alterations in biomechanical behaviors. Repair strategies using biomaterials can be optimized based on biomechanical and biological requirements.
To review current literature on 1) effects of degeneration, simulated degeneration, and injury on biomechanics of the intervertebral disc with special attention paid to needle puncture injuries which are a pathway for diagnostics and regenerative therapies; and 2) promising biomaterials for disc repair with a focus on how those biomaterials may promote biomechanical repair.
A narrative review to evaluate the role of biomechanics on disc degeneration and regenerative therapies with a focus on what biomechanical properties need to be repaired and how to evaluate and accomplish such repairs using biomaterials. Model systems for screening of such repair strategies are also briefly described.
Papers were selected from two main Pubmed searches using keywords: intervertebral AND biomechanics (1823 articles) and intervertebral AND biomaterials (361 articles). Additional keywords (injury, needle puncture, nucleus pressurization, biomaterials, hydrogel, sealant, tissue engineering) were used to narrow articles to the topics most relevant to this review.
Degeneration and acute disc injuries have the capacity to influence nucleus pulposus pressurization and annulus fibrosus integrity, which are necessary for effective disc function, and therefore, require repair. Needle injection injuries are of particular clinical relevance with potential to influence disc biomechanics, cellularity, and metabolism, yet these effects are localized or small, and more research is required to evaluate and reduce potential clinical morbidity using such techniques. NP replacement strategies, such as hydrogels, are required to restore NP pressurization or lost volume. AF repair strategies, including crosslinked hydrogels, fibrous composites, and sealants offer promise for regenerative therapies to restore AF integrity. Tissue engineered intervertebral disc structures, as a single implantable construct, may promote greater tissue integration due to improved repair capacity of vertebral bone.
Intervertebral disc height, neutral zone characteristics and torsional biomechanics are sensitive to specific alterations in nucleus pulposus pressurization and annulus fibrosus integrity, and must be addressed for effective functional repair. Synthetic and natural biomaterials offer promise for NP replacement, AF repair, as an AF sealant, or for whole disc replacement. Meeting mechanical as well as biological compatibility is necessary for the efficacy and longevity of the repair.
Intervertebral disc degeneration; needle injection; biomechanics; injury; biomaterials; hydrogels; sealant; tissue engineering
Destruction of extracellular matrix (ECM) leads to intervertebral disc degeneration (IDD), which underlies many spine-related disorders. Matrix metalloproteinases (MMPs), and disintegrins and metalloproteinases with thrombospondin motifs (ADAMTSs) are believed to be the major proteolytic enzymes responsible for ECM degradation in the intervertebral disc (IVD).
To summarize the current literature on gene expression and regulation of MMPs, ADAMTSs, and tissue inhibitors of metalloproteinases (TIMPs) in IVD aging and IDD.
A comprehensive literature review of gene expression of MMP, ADAMTS, and TIMP in human IDD and reported studies on regulatory factors controlling their expressions and activities in both human and animal model systems.
Upregulation of specific MMPs (MMP-1, -2, -3, -7, -8, -10, and -13) and ADAMTS (ADAMTS-1, -4, and -15) were reported in human degenerated IVDs. However, it is still unclear from conflicting published studies whether the expression of ADAMTS-5, the predominant aggrecanase, is increased with IDD. Tissue inhibitors of metalloproteinase-3 is downregulated, whereas TIMP-1 is upregulated in human degenerated IVDs relative to nondegenerated IVDs. Numerous studies indicate that the expression levels of MMP and ADAMTS are modulated by a combination of many factors, including mechanical, inflammatory, and oxidative stress, some of which are mediated in part through the p38 mitogen-activated protein kinase pathway. Genetic predisposition also plays an important role in determining gene expression of MMP-1, -2, -3, and -9.
Upregulation of MMP and ADAMTS expression and enzymatic activity is implicated in disc ECM destruction, leading to the development of IDD. Future IDD therapeutics depends on identifying specific MMPs and ADAMTSs whose dysregulation result in pathological proteolysis of disc ECM.
Intervertebral disc degeneration; Extracellular matrix; MMPs; ADAMTS; Aging
No clinical trial of spinal manipulation for chronic neck pain, either for single or multiple intervention session(s), has employed an effective sham-manipulation control group.
Validate a practical sham cervical high velocity, low amplitude (HVLA) spinal manipulation.
Randomized, experimental validation study in an institutional clinical research laboratory
Eligible subjects were males and females, 18–60 years of age with mechanical neck pain (as defined by the International Association for the Study of Pain Classification) of at least 3 months duration. Subjects with arm pain, any pathologic cause of neck pain or any contra-indication to spinal manipulation were excluded.
The primary outcome was the patient’s self-report or “registration” of group allocation following treatment. Secondary outcomes were NRS-101 for neck pain, range of motion (by goniometer), tenderness (by pressure algometry).
Eligible subjects were randomly allocated to one of two groups: “real” or sham cervical manipulation (RM or SM). All subjects were given two procedures in sequence, either RM+SM or SM+SM. Immediately following the two procedures, subjects were asked to register any pain experienced during the procedures and to identify their treatment group allocation. Force-time profiles were recorded during all procedures. Secondary clinical outcome measures were obtained at baseline, 5 and 15 minutes after the intervention including range of motion, self-report of pain and local spinous process tenderness. Data for each variable were summarized and tested for normality in distribution. Summary statistics were obtained for each variable and statistically tested. Funding for this study was obtained from the National Institutes of Health (NCCAM: R21 AT004396-01A1) and the Canadian Institutes of Health Research (BMT91926). No conflicts of interest exist in this study.
Sixty-seven subjects were randomized. Data from 64 subjects (32 per group) were available for analysis. There were no significant differences between the groups at baseline. One adverse event occurred in the “real” group which was a mild post- treatment pain reaction lasting < 24 hours. In the RM group, 50% of subjects incorrectly registered their treatment allocation; in the sham group, 53% did so. For the SM group, none of the procedures resulted in cavitation while in the RM group, 87% of procedures resulted in cavitation. There were no significant changes between groups on pain, tenderness or ROM. Force-time profiles of the RM and SM procedures demonstrated fidelity with significant differences between components as intended.
The novel sham procedure has been shown to be effective in masking subjects to group allocation and to be clinically inert with respect to common outcomes in the immediate post-treatment stage. Further research on serial applications and for multiple operators is warranted.
cervical; manipulation; sham; clinical study; neck pain
The prevalence of lumbar spinal stenosis (LSS) in the general population and association with low back pain (LBP) remains unclear.
1) to evaluate the prevalence of congenital and acquired LSS observed on computed tomography (CT) in a community-based sample; 2) to evaluate the association between LSS and LBP.
Cross-sectional observational study. This study was an ancillary project to the Framingham Heart Study.
3529 participants underwent multi-detector CT. 191 were enrolled in this study.
LBP in the preceding 12 months was evaluated using a self-report questionnaire.
LSS (congenital and acquired) was characterized using two cut-points: 12 mm for relative LSS, and 10 mm for absolute LSS.
Using multiple logistic regression we examined the association between LSS and LBP, adjusting for sex, age and BMI.
In the congenital group, relative LSS was found in 4.7% and absolute LSS in 2.6% of patients. Acquired LSS was found in 22.5% and in 7.3%, respectively. Acquired LSS showed increasing prevalence with age: <40 years, the prevalence of relative and absolute LSS was 20.0% and 4.0%, respectively; in those 60–69 years the prevalence was 47.2% and 19.4%, respectively. The presence of absolute LSS was associated with LBP with an odds ratio of 3.16 (95% CI: 1.05–9.53).
The prevalence of congenital and acquired LSS in a community-based sample was characterized. The prevalence of acquired stenosis increased with age. LSS is associated with a three-fold higher risk of experiencing LBP.
spinal stenosis; low back pain; computed tomography; spine; prevalence; community-based sample
The presence of retrolisthesis has been associated with the degenerative changes of the lumbar spine. However, retrolisthesis in patients with L5–S1 disc herniation has not been shown to have a significant relationship with worse baseline pain or function. Whether it can affect the outcomes after discectomy, is yet to be established.
The purpose of this study was to determine the relationship between retrolisthesis (alone or in combination with other degenerative conditions) and postoperative low back pain, physical function, and quality of life. This study was intended to be a follow-up to a previous investigation that looked at the preoperative assessment of patient function in those with retrolisthesis and lumbar disc herniation.
Patients enrolled in SPORT (Spine Patient Outcomes Research Trial) who had undergone L5–S1 discectomy and had a complete magnetic resonance imaging scan available for review (n=125). Individuals with anterolisthesis were excluded.
Time-weighted averages over 4 years for the Short Form (SF)-36 bodily pain scale, SF-36 physical function scale, Oswestry Disability Index (ODI), and Sciatica Bothersomeness Index (SBI).
Retrolisthesis was defined as a posterior subluxation of 8% or more. Disc degeneration was defined as any loss of disc signal on T2 imaging. Modic changes were graded 1 to 3 and collectively classified as vertebral end plate degenerative changes. The presence of facet arthropathy and ligamentum flavum hypertrophy was classified jointly as posterior degenerative changes. Longitudinal regression models were used to compare the time-weighted outcomes over 4 years.
Patients with retrolisthesis did significantly worse with regard to bodily pain and physical function over 4 years. However, there were no significant differences in terms of ODI or SBI. Similarly, retrolisthesis was not a significant factor in the operative time, blood loss, lengths of stay, complications, rate of additional spine surgeries, or recurrent disc herniations. Disc degeneration, modic changes, and posterior degenerative changes did not affect the outcomes.
Although retrolisthesis in patients with L5–S1 disc herniation did not affect the baseline pain or function, postoperative outcomes appeared to be somewhat worse. It is possible that the contribution of pain or dysfunction related to retrolisthesis became more evident after removal of the disc herniation.
Retrolisthesis; Postoperative; Lumbar discectomy; Lumbar disc herniation; Degenerative lumbar disease
Few studies have directly evaluated the association of lumbar lordosis and segmental wedging of the vertebral bodies and intervertebral disks with prevalence of spinal degenerative features.
To evaluate the association of CT-evaluated lumbar lordosis, segmental wedging of the vertebral bodies and that of the intervertebral disks with various spinal degeneration features.
This cross-sectional study was a nested project to the Framingham Heart Study.
A random consecutive subset of 191 participants chosen from the 3590 participants enrolled in the Framingham Heart Study who underwent multi-detector CT to assess aortic calcification.
Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis, spondylolysis, spondylolisthesis and spinal stenosis and density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on supine CT, as well as the lordosis angle (LA) and the wedging of the vertebral bodies and intervertebral disks. Sum of vertebral bodies wedging (ΣB) and sum of intervertebral discs wedging (ΣD) were used in analyses.
Mean values (±SD) of LA, ΣB and ΣD were calculated in males and females and compared using the t-test. Mean values (±SD) of LA, ΣB and ΣD in 4 age groups: <40, 40–49, 50–59 and 60+ years were calculated. We tested the linear relationship between LA, ΣB and ΣD and age groups. We evaluated the association between each spinal degeneration feature and LA, ΣB and ΣD using multiple logistic regression analysis where studied degeneration features were the dependent variable and all LA, ΣB and ΣD (separately) as well as age, sex, and BMI were independent predictors.
LA was slightly lower than the normal range for standing individuals, and no difference was found between males and females (p=0.4107). However, the sex differences in sum of vertebral bodies wedging (ΣB) and sum of intervertebral discs wedging (ΣD) were statistically significant (0.0001 and 0.001, respectively). Females exhibit more dorsal wedging of the vertebral bodies and less dorsal wedging of the intervertebral discs than do males. All these parameters showed no association (p>0.05) with increasing age.
LA showed statistically significant association with presence of spondylolysis (OR(95%CI): 1.08(1.02–1.14)) and with density of multifidus (1.06 (1.01–1.11). as well as a marginally significant association with isthmic spondylolisthesis (1.07(1.00–1.14). ΣB showed a positive association with degenerative spondylolisthesis and disc narrowing ((1.14(1.06–1.23) and 1.04 (1.00–1.08), correspondingly), whereas ΣD showed negative one (0.93(0.87–0.98) and (0.93(0.89–0.97), correspondingly).
Significant associations were found between lumbar lordosis evaluated in supine position and segmental wedging of the vertebral bodies and intervertebral disks and prevalence of spondylolysis and spondylolisthesis. Additional studies are needed, to evaluate the association between spondylolysis, isthmic and degenerative spondylolisthesis and vertebral and disc wedging at segmental level.
computer tomography; spine; degeneration; lordosis; segmental wedging angle; vertebral body; intervertebral disc
Although the role of radiographic abnormalities in the etiology of nonspecific low back pain (LBP) is unclear, the frequent identification of these features on radiologic studies continues to influence medical decision making.
The primary purposes of the study were to evaluate the prevalence of lumbar spine degeneration features, evaluated on computed tomography (CT), in a community-based sample and to evaluate the association between lumbar spine degeneration features. The secondary purpose was to evaluate the association between spinal degeneration features and LBP.
This is a cross-sectional community-based study that was an ancillary project to the Framingham Heart Study.
A subset of 187 participants were chosen from the 3,529 participants enrolled in the Framingham Heart Study who underwent multidetector CT scan to assess aortic calcification.
Self-report measures: LBP in the preceding 12 months was evaluated using a Nordic self-report questionnaire. Physiologic measures: Dichotomous variables indicating the presence of intervertebral disc narrowing, facet joint osteoarthritis (OA), spondylolysis, spondylolisthesis, and spinal stenosis and the density (in Hounsfield units) of multifidus and erector spinae muscles were evaluated on CT.
We calculated the prevalence of spinal degeneration features and mean density of multifidus and erector spinae muscles in groups of individuals with and without LBP. Using the χ2 test for dichotomous and t test for continuous variables, we estimated the differences in spinal degeneration parameters between the aforementioned groups. To evaluate the association of spinal degeneration features with age, the prevalence of degeneration features was calculated in four age groups (less than 40, 40–50, 50–60, and 60+ years). We used multiple logistic regression models to examine the association between spinal degeneration features (before and after adjustment for age, sex, and body mass index [BMI]) and LBP, and between all degeneration features and LBP.
In total, 104 men and 83 women, with a mean age (±standard deviation) of 52.6±10.8 years, participated in the study. There was a high prevalence of intervertebral disc narrowing (63.9%), facet joint OA (64.5%), and spondylolysis (11.5%) in the studied sample. When all spinal degeneration features as well as age, sex, and BMI were factored in stepwise fashion into a multiple logistic regression model, only spinal stenosis showed statistically significant association with LBP, odds ratio (OR) (95% confidence interval [CI]): 3.45 [1.12–10.68]. Significant association was found between facet joint OA and low density of multifidus (OR [95% CI]: 3.68 [1.36–9.97]) and erector spinae (OR [95% CI]: 2.80 [1.10–7.16]) muscles.
Degenerative features of the lumbar spine were extremely prevalent in this community-based sample. The only degenerative feature associated with self-reported LBP was spinal stenosis. Other degenerative features appear to be unassociated with LBP.
Low back pain; Computed tomography; Spine; Degeneration
intervertebral disc; injury; biomechanics; animal model
Despite the common prevalence of lumbar spine and degenerative hip disorders, there are few descriptions of patients with coexisting hip and lumbar spine disorders. The independent economic burden of each disorder is substantial but the financial burden when the disorders are coexisting is unknown.
The purpose of this study is to determine the prevalence of coexisting hip and lumbar spine disorders (LSD) in a large cohort of patients with hip osteoarthritis treated with total hip arthroplasty (THA) and determine the impact on pain and functional THA outcomes and physician charges.
This is a retrospective study performed at a tertiary university.
3206 patients who underwent total hip replacement from 1996-2008.
Self-report measures: Visual Analog Scale. Functional measures: modified Harris Hip Score (mHHS), UCLA hip questionnaire. Economic impact measures: physician medical charges.
International Classification of Diseases (ICD-9) billing codes related to LSDs were cross referenced with the 3206 patients who had undergone a THA to determine which patients were also evaluated by a spine specialist. Demographic, hip clinical outcomes and physician charges for patients with THA alone (THA alone) were compared to patients treated with THA and diagnosed with a LSD (THA + LSD).
Of 3206 patients who underwent THA, 566 (18%) were also evaluated by a spine specialist. Of those with a LSD, 334 (59%) were women with an older average age (64.5+13.3yrs) compared to patients treated with THA alone (51%, 58.5+15.5 yrs, P=0.0001). Patients in the THA alone group as compared to the THA+ LSD group had greater improvement in the mHHS (P =0.0001), UCLA score (P =0.0001) and pain (P=0.0001). Patients in the THA+LSD group incurred on average $2,668 more in charges per episode of care as compared to patients in the THA alone group. (P<0.001) Patients in the THA+LSD group had more days per episode of care (P=0.001).
Patients undergoing THA alone had greater improvement in function and pain relief with fewer medical charges as compared to patients undergoing a THA and treatment for a LSD. The prevalence of coexisting hip and spine disorders is likely higher than currently documented. Further study is needed in order to improve therapeutic recommendations and determine the potential for reduction in medical expenses associated with concurrent treatment of hip osteoarthritis and lumbar spine disorders.
hip; arthroplasty; lumbar spine; low back pain; osteoarthritis; hip-spine syndrome