Multidisciplinary or monodisciplinary chiropractic treatment of low back pain?

Researchers in the United States have investigated the differences, advantages, and disadvantages of monodisciplinary chiropractic treatment or multidisciplinary treatment for subacute and chronic low back pain and compared the two treatment modalities. They concluded that patients who received multidisciplinary care tended to do slightly better than patients who received monodisciplinary chiropractic treatment, but that the difference between the two groups was relatively small. Given the resources required to successfully implement multidisciplinary treatment teams, multidisciplinary treatment of low back pain may not be worthwhile compared to monodisciplinary chiropractic treatment.

Which factors could determine the choice?
Interdisciplinary treatment has been a way to integrate different forms of treatment to meet patients' needs in a more comprehensive way, but interdisciplinary approaches can have significant challenges, according to the researchers. They can be difficult to manage because they require multiple appointments with different providers along with the significant resources needed to coordinate multidisciplinary care. All this can contribute to an incoherent and unsatisfactory treatment.

Moreover, the results of this and other studies suggest that there are only modest benefits in terms of clinical outcomes of multidisciplinary treatment. The patients who received the treatment did better on the primary outcome, pain intensity over 1 year, but this was not a significant improvement. Although they consistently reported greater percentage reductions in pain intensity than those receiving monodisciplinary chiropractic treatment, they were generally small (< 10%). In the long term, multidisciplinary treatment was of significant benefit in relation to some secondary measures (disability, improvement, satisfaction, and frequency of low back symptoms) but not in relation to others (medication use, quality of life, frequency of leg symptoms, fear-avoidance beliefs, self-efficacy, active pain management and anxiety to move).

It is also important to note that the patients who received multidisciplinary treatment in this study received an average of nearly 24 treatments compared to 18 treatments in the monodisciplinary chiropractic treatment group, and many of the treatments were significantly longer than a typical chiropractic treatment. This has potential implications for the costs of multidisciplinary treatments for both the healthcare system and patients, and they pose additional barriers to effective pain management, especially for those who are financially challenged. It is likely that offering these resource-intensive approaches will not be cheaper. E.g., monodisciplinary chiropractic treatment has been shown to be less expensive than more structurally intensive treatments for elderly patients with neck pain.

How was the study carried out?
The study was carried out as a randomized clinical trial. 201 patients participated in the study. All participants were 18 years of age or older, with back pain, stiffness, or tenderness with or without leg pain or neurological signs, and all had suffered a current episode of low back pain for 6 weeks or longer. All participants received 12 weeks of treatment, either monodisciplinary chiropractic treatment or multidisciplinary team-based treatment. Monodisciplinary chiropractic treatment was provided by chiropractors. Multidisciplinary team-based treatment was coordinated by case managers and delivered by a team of acupuncturists, chiropractors, psychologists, exercise therapists, massage therapists, and primary care physicians.

The patients themselves evaluated their response to the treatment in connection with each treatment. Each patient indicated the symptom and activity most affected by their low back pain and rated the treatment on a scale of 0-10.

After the data was collected, it was analysed and the analysis used as the basis for the researchers' conclusions. The study was documented in the scientific article "Multidisciplinary integrative care versus chiropractic care for low back pain: a randomized clinical trial", which was named the best article in 2022 by Chiropractic & Manual Therapies.

Gert Bronfort, Michele Maiers, Craig Schulz, Brent Leininger, Kristine Westrom, Greg Angstman, Roni Evans. Multidisciplinary integrative care versus chiropractic care for low back pain: a randomized clinical trial. Chiropractic & Manual Therapies 2022.