Description of outcomes, patient experiences and related costs of care in low back pain patients undergoing chiropractic treatment in the UK

  • Taco August Wilhelm Houweling

Student thesis: Doctoral Thesis


Rationale: The prevalence of low back pain and associated costs to society are high. Despite this, the number of studies investigating observational data on the quality and costs of care in routine health care services, such as chiropractic, is relatively small in comparison to the clinical trial evidence available on the effectiveness and cost-effectiveness of manual therapies for low back pain.

Objective: To document the quality and cost of care in low back pain patients undergoing routine chiropractic care in the United Kingdom.

Design: Prospective single cohort multi-centre study.

Participants: A sample of 120 chiropractors and 421 patients.

Methods: Following the development of a data collection instrument and a pilot study, patients suffering from low back pain were recruited by chiropractic clinics in the United Kingdom. Information was recorded using a patient self-report questionnaire at baseline prior to the initial consultation, and participants were mailed a follow-up questionnaire at three months. Health outcomes, patient experiences of the process and safety of care, and related costs in the intervening three month period were documented.

Results: Four hundred and twenty-one patients formed the baseline sample, and 238 (57%) of these returned the follow-up questionnaire at three months. Statistically significant change scores (p = 0.0001) were seen for the health status measures including the Roland-Morris Disability Questionnaire, Bournemouth Questionnaire, EuroQol-5D and bothersomeness scale. One hundred and sixty-eight of 238 (70%) patients reported a clinically significant improvement on the Perceived Global Effect scale, and 73 (31%) of these were considered recovered anytime during the study period using definitions of recovery (i.e. acceptable quality of life, no disability and no pain for a whole month). One hundred and twenty-nine (54%) of patients at follow-up rated chiropractic care for their low back condition as ‘very helpful’. The number of patients rating the process of care (i.e. time and explanations given by chiropractor as well involvement in decisions about care) as ‘very good’ ranged from 157 to 168 (66% to 71% respectively of the patients at follow-up). One hundred and twenty-five (52%) of patients at follow-up reported adverse events of care (i.e. worsening of their back pain, stiffness, soreness and/or general discomfort immediately or shortly after the chiropractic treatment visits); however, only 13 (5%) of these reported that they were unable to carry on with their usual activities and/or work as a result of these events. On average, the total cost of care was £481.83 (95% CI = 333.17 to 639.42) per patient. Lost productivity resulting from time away from work was the most important contributor to these costs (59.6%). The cost of chiropractic visits was the second most important contributor, which accounted for nearly one-third of total costs (32.8%). Other health care usage including general practitioner visits, medical procedures and diagnostic imaging were responsible for a small proportion of total costs ranging from 0.4% to 1.6%.

Conclusions: This programme of research is the first prospective study conducted in routine chiropractic practice simultaneously documenting information about health outcomes and patient experiences and costs of care. Patients improved markedly within the first three months of care and expressed high satisfaction with the chiropractic treatment and consultation they received. Chiropractic care was relatively safe, with common yet benign adverse events that had little influence on activities of daily living. Taken overall, patients receiving chiropractic care reported improvement at arguably reasonable cost, suggesting this approach to the health care of patients with low back pain be considered in the wider context of health care delivery in the United Kingdom.
Date of AwardJan 2013
Original languageEnglish
Awarding Institution
  • University of Portsmouth
SupervisorGraham Mills (Supervisor) & Jennifer E. Bolton (Supervisor)

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