Anheuser-Busch is the world’s leading brewing company. One of their wholesalers, Brewers Distributing, is located in Peoria, IL. Many of their employees spend most of their time moving around heavy cases and kegs of beer. “Having noticed a large number of workers compensation cases due to lifting-related injuries, the company decided to introduce several workplace wellness programs to prevent these injuries from occurring in the first place. One of these programs involved weekly, on-site chiropractic visits, free of charge to any employee.” The chief financial officer at Brewers Distributing believes that on-site chiropractic has given his employees the greatest benefit.

The on-site chiropractic services at Brewers Distributing are provided by a young, new graduate chiropractor, who is also establishing his practice in Peoria. He works on-site at Brewers Distributing on Thursdays. The cost to the employee for this on-site chiropractic care is free (the doctor is paid by Brewers Distributing). If an employee needed help outside of that weekly window of time, they can visit the doctor in his office.

The strategy at Brewers Distributing is that by treating minor musculoskeletal problems their employees develop, they are preventing such problems from developing into a serious injury that would need to be covered by workers’ compensation. The view is that it is a win-win-win situation, a strategy that benefits the employee, which reduces costs, which benefits the employer.

The author of the article, Annie Locke, notes (1):

“While some business owners and administrators might dismiss such a program as too expensive, it has actually saved Brewers a significant amount of money. In the two years since it was implemented, the number of employee sick days has declined by 22 percent, while the accident rate has been cut in half. Consequently, the company’s workers’ compensation costs have experienced a dramatic reduction, with premiums declining by more than 25 percent.”

“With that in mind, Brewers has encouraged others to adopt similar programs. At a recent industry conference, the company’s on-site chiropractic program was recognized as a ‘best practice’ among the hundreds of attendees. Katie Waddington, human resources manager, presented information about the program at the conference. ‘A lot of people at first think, Oh my goodness, that costs to have a chiropractor in your facility!’ But when you really look at the numbers… it makes sense. We have the return on investment and the statistics to prove it.’”

••••••••••

One hundred sixteen million (116,000,000) Americans suffer from chronic pain (2). Their pain is distributed as follows (3):

Low Back Pain 28.1%

Knee Pain 19.5%

Severe Headache/Migraine 16.1%

Neck Pain  15.1%

Shoulder Pain  09.0%

Finger Pain 07.6%

Hip Pain 07.1%

Back pain, neck pain and severe headache/migraine comprise some of the most prevalent chronic medical problems in America. Back and neck pain are found among approximately 25% of the US population aged 18 to 44 years and 33% of the US population aged 45 to 64 years. Severe headaches or migraines are found in approximately 20% of the population aged 18 to 44 years and 15% aged 45 to 64 years (4):

	Back Pain and Neck Pain	Severe Headache or Migraine
18-44 years	25%	20%
45-64 years	33%	15%

The direct costs in the United States for the treatment of back and neck pain are escalating (5):

• A 65% total cost increase between 1997-2005.

• A 171% increase in drug costs between 1997-2005.

Back problems are the second most common cause of disability in the United States, accounting for tens of billions of dollars in lost wages (6).

Chiropractic care has a proven record as an effective treatment for back pain, neck pain, and headache. A few such examples are briefly presented here:

• A clinical trial including 283 patients with chronic, serious, disabling, and treatment resistant low back pain with side-posture chiropractic spinal manipulation. The chiropractic spinal manipulation achieved an acceptable clinical outcome in 81% of the subjects who were suffering from referred pain syndromes, and in 41% of those who were suffering from compressive neuropathology. The authors concluded: “the physician who makes use of this [manipulation] resource will provide relief for many back pain patients.” (7)
• A clinical trial including 28 patients with chronic, treatment resistant neck pain subsequent to a whiplash-type injury. These patients had failed to improve with anti-inflammatory drugs, and were referred for specific chiropractic spinal manipulation. Ninety-three percent of the patients showed meaningful clinical improvement. The authors concluded: “The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.” (8)
• A randomized clinical trial (1990) compared chiropractic to hospital outpatient management for patients with mechanical low back pain. The study involved 741 patients aged 18-85, with a 2-year follow-up period. The authors concluded: “chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain.” (9)
• A nine-week randomized clinical trial (2003) comparing prescription NSAID medication, needle acupuncture, and chiropractic spinal manipulation for patients with chronic neck and back pain (10). The chiropractic spinal manipulation was better than five times more effective than the drugs and nearly three times more effective that needle acupuncture. Importantly, no chiropractic subjects suffered from any adverse side effects, and the musculoskeletal benefits largely remained stable at the one-year follow-up (11).
• A randomized double-blinded clinical trial (2004) of patients with sub-acute low back pain showed that patients receiving chiropractic adjustments experienced significantly more pain relief compared with those receiving sham adjustments or muscle relaxants (12).
• A comprehensive literature review (2007) found that spinal manipulation was beneficial for patients with chronic mechanical neck pain at 6 weeks, 12 weeks, and up to 2 years after treatment (13).
• A systematic literature review (2011) of controlled clinical trials found evidence supporting the use of spinal manipulation for migraine and cervicogenic headache (14).
• A hazard ratios study (2011) comparing chiropractic, physical therapy, and physician care in 894 work related low back pain cases, followed for one year. The patients under chiropractic care were significantly less likely to have a recurrence of low back pain. The chiropractic patients also had shorter periods of disability (they returned to work earlier), and had “fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups.” (15)
• A randomized clinical trial (2012) comparing chiropractic spinal manipulation, medication, or home exercise with advice for patients with acute and sub-acute neck pain. The study assessed 272 subjects aged 18 to 65 years with a follow-up of one year. The outcomes showed chiropractic spinal manipulation to be significantly more effective and safer than medications, and significantly less time consuming than engaging in exercise/advice (16).

••••••••••

Chiropractic care offered at an on-site health center has the potential to reduce the economic costs and the clinical burden of musculoskeletal conditions.

Searching the National Library of Medicine using the “PubMed” search engine with the key words “on-site chiropractic” two pertinent articles are found, and reviewed below.

Value of Chiropractic Services at an On-Site Health Center
Journal of Occupational and Environmental Medicine
August 2012; Vol. 54; No. 8; pp. 917-921

Curt A. Krause, DC, Lisa Kaspin, PhD, Kathleen M. Gorman, MPH, Ross M. Miller, MD, MPH (17)

Chiropractic care has been demonstrated to be an effective treatment for back pain, neck pain, and headache. This study is a retrospective claims analysis and clinical evaluation that was performed to assess the influence of on-site chiropractic services on health care utilization and outcomes. It may be the first study to evaluate the impact of chiropractic when offered at an on-site [work place] health center.

The on-site health centers’ mission was to enhance patients’ health, promote patient satisfaction, increase productivity, and decrease absenteeism by delivering convenient and excellent care in a high-tech work place environment. Utilization of on-site chiropractic services offers patients more convenient care than they would receive off-site. Given the convenience and quality of care provided by on-site health centers, it was hypothesized that on-site chiropractic care would be more beneficial than off-site clinic care.

To determine the effectiveness of the on-site chiropractic care, patients were asked to complete functional-assessment questionnaires appropriate to their care:

• Headache Disability Index (HADI)
• Neck Pain Disability Index (NPDI)
• Oswestry Low Back Pain Questionnaire (OLBQ)

Patients with headache, neck pain, and low back pain who were treated with chiropractic on-site showed significant improvement in both pain and functional status:

Efficacy of On-site Chiropractic Care in Functional Status

Questionnaire	Percent Improvement
Headache Disability Index (HADI)	19%
Neck Pain Disability Index (NPDI)	15%
Oswestry Low Back Pain Questionnaire (OLBQ)	15%

Research has shown that functional improvements resulting from chiropractic care increase the ability to perform work-related activities.

In claims for musculoskeletal injuries treated by medical doctors and chiropractors, treatment by chiropractors, resulted in fewer lost workdays and lower workers’ compensation payment. There is evidence that patients with chiropractic coverage will directly substitute chiropractic care for medical care.  Chiropractic patients have lower utilization of ancillary medical services.

Patients treated at the off-site chiropractic office were significantly more likely to have a physical therapy visit and an outpatient physician visit. Patients in the on-site chiropractic group had lower odds of having a physical therapy visit and also had fewer physical therapist visits.  In this study, “patients receiving chiropractic care on-site were less likely to have a physical therapy visit and outpatient [physician] visit.”

These authors made these following points:

“Chiropractic care offered at an on-site health center could reduce the economic and clinical burden of musculoskeletal conditions.”

“Patients treated off-site were significantly more likely to have physical therapy and outpatient visits. In addition, the average total number of health care visits, radiology procedures, and musculoskeletal medication use per patient with each event were significantly higher for the off-site group.”

“These results suggest that chiropractic services offered at on-site health centers may promote lower utilization of certain health care services, while improving musculoskeletal function.”

“The average total numbers of health care visits, radiology procedures, and musculoskeletal medication use per patient with each event were significantly higher for the off-site group.”

“Significant reductions in all functional assessment measures were observed, suggesting that the cohort experienced substantial improved functional status for all the three musculoskeletal conditions.” “Further evidence of the on-site chiropractic care’s effectiveness is the change in patient-    reported functional status after treatment. That is, over the study period, there was a statistically significant decrease in the average HADI, NPDI, and OLBQ scores.” “These findings confirm that on-site chiropractic care successfully improved patients’ daily functioning.”

“Compared with alternatives, including physician visits, hospitalizations, and surgery, chiropractic care is considered a cost-effective treatment.”

“[Treatment with] on-site chiropractic services was associated with lower utilization of certain health care services, as well as improved functional outcomes.”

“The results of this study support the value of chiropractic services offered at on-site health centers.”

In this study, “the average total numbers of health care visits, radiology procedures, and musculoskeletal medication use per associate with each event were significantly lower for the on-site [chiropractic] group.”

These authors suggest that on-site chiropractic care is used as an alternative to off-site physical therapy and physician care. “Lower health care utilization among the on-site group may also be related to the characteristics of effective chiropractic care.”

There is evidence that chiropractic care is less invasive and more conservative than alternative treatments. “Patients with chiropractic coverage seemed to be avoiding more surgeries, hospitalizations, and radiographic imaging procedures.”

The improved functional status found in this analysis indicates potential for reduced indirect costs, including absenteeism and productivity losses, with on-site chiropractic services.

This unique study highlights the potential benefits for all [employees, employers, costs benefits] concerned by offering on-site chiropractic services for employees,

••••••••••

Impact of Chiropractic Services at an On-Site Health Center
Journal of Occupational and Environmental Medicine
September 2014; Volume 56; No. 9; pp. 990–992

Sylvia L. Kindermann, MPH; Qingjiang Hou, MS; Ross M. Miller, MD, MPH (18)

The objective of this study was to compare the influence of employer-sponsored, on-site chiropractic care against community-obtained care on health care utilization. It was a retrospective claims analysis study, using 876 on-site and 759 off-site participants.

Doctors of chiropractic promote wellness and injury prevention. Chiropractic care has been demonstrated to deliver effective treatment for the symptoms of musculoskeletal conditions. On-site chiropractic care has been shown to deliver substantial value through convenience of access, high quality of care and delivery, and lowered overall costs.

Employer-sponsored worksite clinics could control costs and increase workplace productivity while providing high quality and convenient care to their employees.

These authors make these background points:

• Musculoskeletal conditions are the primary cause of physical disability in the United States.
• About 50% of US adults have back pain, arthritis, osteoporosis, or bodily injury in excess of 3 months’ duration annually.
• Seventeen percent of US workers have absenteeism as a result of musculoskeletal conditions yearly.
• Neck pain inhibits about 14% of workers from successfully completing their jobs.

• In 2006, the average direct cost of treatment for musculoskeletal conditions was $576 billion, and indirect costs added an additional $373 billion, primarily in wage losses; a total cost of $949 billion.

In this study, the authors found:

• “The mean number of chiropractic services and physical therapy visits per member were both significantly higher in the off-site group.”
• “Patients receiving chiropractic care on-site were significantly less likely to have radiology [diagnostic imaging, including MRI, ultrasound, and x-rays] testing.”
• The off-site group received more radiology services overall (55.5% vs 38.2%) including magnetic resonance imaging, ultrasound, and radiograph; had higher outpatient and emergency department utilization; and demonstrated greater use of chiropractic care and physical therapy.

[numbers rounded]	On-Site Chiropractic Care	Off-site Chiropractic Care
Diagnostic Imaging (X-ray, MRI, Ultrasound)	38%	56%
(X-ray)	27%	46%
(MRI)	12%	15%
(Ultrasound)	11%	16%
Repeated Diagnostic Imaging	19%	30%
Outpatient Utilization	30%	47%
Emergency Department Visits	13%	19%

These authors state:

On-site chiropractic care has “demonstrated significant improvements in headache, neck pain, and low back pain functional status in patients utilizing on-site services over a short time frame while still showing lower utilization and cost outcomes than community-based care.”

“This study demonstrates that users of on-site chiropractic services have lower health care utilization than those who obtain their care at off-site community care centers.”

“The results of this study support the value of chiropractic services offered at on-site health centers in comparison with chiropractic services provided off-site. Future research into potential indirect and direct cost savings would supplement this study and further demonstrate the advantages of on-site chiropractic care.”

“Compared with off-site care, on-site chiropractic services are associated with lower health care utilization. These results support the value of chiropractic services offered at on-site health centers.”

SUMMARY

These studies suggests that all work places should offer on-site chiropractic services because:

• It is convenient for the employee, enhancing employee satisfaction.

• It is very effective in reducing the employees pain and disability.
• It reduces costs.
• It is extremely safe.
• It reduces worker absenteeism.
• It reduces the use of drugs.
• It reduces hospitalization.
• It reduces visits to physical therapists and to physicians.
• It reduces the utilization of a number of diagnostic imaging procedures.
• It increases employee productivity.
• It appears that on-site chiropractic services reduce costs, benefits the employee, and benefits the employer.

REFERENCES 

1. Locke A; Saving Backs… and Costs; On-site Chiropractic Care Can Improve Employee Health While Cutting Overall Costs; Peoria Magazines, InterBusiness Issues; September 2014; pp. 83-84.
2. Pho K; Pain Management: Education is Key; USA Today; September 19, 2011.
3. Where it Hurts; Wall Street Journal; October 7, 2013.
4. US Department of Health and Human Services; Centers for Disease Control and Prevention, National Center for Health Statistics; 2010; Severe headache or migraine, low back pain, and neck pain among adults 18 years of age and over, by selected characteristics; Available at: http://www.cdc.gov/nchs/data/hus/hus10.pdf#126.
5. Martin BI, Deyo RA, Mirza SK, et al.; Expenditures and health status among adults with back and neck problems; Journal of the American Medical Association; 2008; Vol. 299; pp. 656–664.
6. Centers for Disease Control and Prevention; Prevalence and most common causes of disability among adults—United States, 2005; Morb Mortal Weekly Report; 2009; Vol. 58; p. 421.
7. Kirkaldy-Willis KH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
8. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic treatment of chronic ‘whiplash’ injuries; Injury; Volume 27; Issue 9; November 1996; pp. 643-645.
9. Meade TW, Dyer S, Browne W, Townsend J, Frank AO; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300, June 2, 1990, pp. 1431-7,
10. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July  15, 2003; Vol. 28; No. 14; pp. 1490-1502.
11. Muller R, Giles LGF; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005; Volume 28; Number 1; pp. 3-11.
12. Hoiriis KT, Pfleger B, McDuffie FC, et al; A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain; J Manipulative Physiol Ther; 2004; Vol. 27; pp.388–398.
13. Vernon H, Humphreys K, Hagino C; Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials; J Manipul Physiol Ther; 2007; Vol. 30; pp. 215–227.
14. Bryans R, Descarreaux M, Duranleau M, et al; Evidence-based guidelines for the chiropractic treatment of adults with headache; J Manipul Physiol Ther; 2011; Vol. 34; pp. 274–289.
15. Cifuentes M, Willetts J, Wasiak R; Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence; Journal of Occupational and Environmental Medicine; April, 2011; Vol. 53; No. 4; pp. 396-404.
16. Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y; Grimm RH; Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial; Annals of Internal Medicine; January 3, 2012; Vol. 156; pp. 1-10,
17. Krause CA, Kaspin L; Gorman KM; Miller RM; Value of Chiropractic Services at an On-Site Health Center; Journal of Occupational and Environmental Medicine; August 2012; Vol. 54; No. 8; pp. 917-921.
18. Kindermann SL, Hou Q, Miller RM; Impact of Chiropractic Services at an On-Site Health Center; Journal of Occupational and Environmental Medicine; September 2014; Volume 56; No. 9; pp. 990–992.