Skip to main content
Download PDF

The primary spine practitioner as a new role in healthcare systems in North America

Chiropractic & Manual Therapies volume 30, Article number: 6 (2022) Cite this article

Abstract

Background

In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies.

Main body

The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly.

Conclusion

Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.

Introduction

Over 25 years ago Waddell described the management of low back pain as a “twentieth century medical disaster” [1]. This was followed by a series of publications calling for comprehensive changes in the approach to low back pain (LBP) by health care systems [2,3,4,5,6,7]. Despite all this discussion, the situation in the twenty-first century has actually worsened. Spine-related disorders (SRDs), defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, are now the most prevalent cause of disability and lost workdays around the world [8, 9], and spending has skyrocketed [10].

A recent strategy has been to increasingly shift focus in healthcare toward primary care. In nearly all areas of medicine, emphasizing primary care practitioners as the initial point of contact for most patients leads to decreased reliance on specialists [11]. However, in the area of SRDs this strategy is problematic. Medical education has not provided primary care practitioners with an extensive background in musculoskeletal diagnosis and management, including evidence-based nonpharmacologic approaches [12, 13].

A recent pragmatic trial of patients with acute LBP treated in primary care found that almost half of the patients received recommendations that were not consistent with leading LBP guidelines [14]. More alarming was the finding that exposure to guideline-non-concordant primary care was an independent risk factor for the transition from acute to chronic LBP. Attempts to provide education about LBP guidelines to improve primary care for patients with SRDs have largely failed [15]. In the area of SRDs, a different approach is needed.

In 2011, a commentary article was published entitled “The establishment of a primary spine care practitioner and its benefits to health care reform in the United States” [16]. This article was an expansion of a concept initially introduced by Haldeman [17], who advocated for the use of practitioners specifically trained in primary-level spine care. Others have since written on this topic [18].

We define the primary spine practitioner (PSP) as a specially-trained clinician (most often a chiropractor or physical therapist) who practices at the top of their license, playing a primary role in the diagnosis, management, referral, and case coordination of patients with SRDs. The model proposes that this specialized professional is needed in the primary-level management of patients with SRDs. The knowledge, skills and responsibilities required of this professional are detailed in our initial paper [16].

The PSP model responds to the need for greater efficiency and effectiveness in the management of patients with SRDs [6]. There has been increased attention to this issue in recent years. However, a predominantly low-value environment still dominates spine care, in which medication, imaging, injection and surgery are emphasized [19]. Significant inroads into the PSP model have taken place over the past 10 years, although health care systems as a whole have not yet fully embraced the concept. The purpose of this article is to discuss the evolution and present status of the PSP model, the role of the PSP in the larger picture of “primary spine care”, and future strategies toward broader adoption of the PSP role.

Primary spine care and the PSP

“Primary Spine Care” is a general term that refers to any activity involving a primary-level health care professional who has early contact or may participate in the “front end” care and coordination of a patient with a SRD [20]. These activities include diagnosis, investigation, management, patient education, and referral to other healthcare providers. We use the term “Primary Spine Practitioner” to identify one of the key professionals who participate in primary spine care.

We propose that the ideal application of the PSP role is to serve as the first contact for majority of patients with SRDs, analogous to the role that the general dentist plays in the area of oral health [16]. However, we recognize that many of these patients will continue in the foreseeable future to consult with primary care practitioners, emergency departments, and urgent care personnel as their first-contact providers for spine care. Therefore, in the context of “Primary Spine Care” we suggest that another useful application of PSPs is to function as intermediary providers between traditional primary care practitioners and specialists. This application of primary spine care requires the coordinated activity of “front end” practitioners that include generalists (e.g., traditional primary care practitioners) and focused primary-level practitioners (PSPs). We posit that the vast majority of patients with SRDs can be managed purely at the primary spine care level, without the need for diagnostic investigations, specialty referrals or invasive procedures.

The primary spine care model has the potential to provide many benefits to different stakeholders in health care systems (although more data are needed, and thus some of these potential benefits are speculative), including:

  • Patients: A more coordinated, consistent, efficient and affordable management of SRDs. This may lead to better clinical outcomes and greater patient satisfaction [21].

  • Providers: Reduced burden on primary care practitioners [21], and for specialists a shorter wait time and a more appropriate case mix [22].

  • Employers: Reduced direct and indirect costs associated with SRDs, such as earlier return to work, increased productivity and decreased absenteeism.

  • Payers: Reduced variation in the management of SRDs, and lower costs per case as a result of improved decision making and a decrease in inappropriate imaging and invasive procedures [23].

  • Governments: More efficient utilization of the healthcare workforce by enabling physical therapists (PTs) and chiropractors (DCs) to work at the “top of their license” [24], easing the burden on other medical personnel.

Barriers to the implementation of the PSP model

Several barriers were identified in our previous publication [16]. Many of these barriers still remain today, but significant strides have been made in several areas.

Educational changes

Although there has not been widespread adoption of PSP training in North America, we have encountered less resistance than we had 10 years ago [16]. In fact, some institutions have moved toward preparing their students to play the PSP role [25, 26].

In addition, the University of Pittsburgh has developed a post-professional PSP certificate program, which was initially launched in December of 2017 [27]. This program consists of combined online distance education and live weekend workshops, which have been organized into four “Units” of instruction. The four units total about 120 h of instruction over the course of approximately one year.

Applicants are PTs and DCs who are required to have certain prerequisite skills such as differential diagnosis/ medical screening, manipulation and other manual therapies, and application of rehabilitative exercise. Attendees are taught advanced application of evidence-informed, patient-centered spine care as well as team-based care and functioning in the role of PSP, providing “primary care for spine patients”. Learning objectives include: primary diagnosis and management, self-care management, application of the principles of Cognitive-Behavioral Therapy [28], Acceptance and Commitment Therapy [29] and Motivational Interviewing [30], decision-making regarding referrals and follow-up, disability management, inter-professional communication, and more.

Legislative and regulatory changes

A number of proposals have arisen in recent years to improve the efficiency and effectiveness of health care. The Institute for Health Care Improvement has identified the need for practitioners to work “at the top of their license” in maximizing utilization of available professionals [24]. The Institute of Medicine has called for a “retooling” of the existing workforce [31], to enable professionals to play new roles and to bring needed innovations, designed to improve value in health care. Dower et al. [32] have emphasized the need to restructure professionals’ scopes of practice to empower them to fill new roles. Goertz et al. recognized the need of such “redeployment” as it specifically applies to the PSP model [18]. However, significant legislative and regulatory obstacles exist that impair the ability of non-allopathic professionals, particularly DCs and PTs, to fully engage in the provision of PSP services.

For example, in many jurisdictions neither DCs nor PTs have the right to order appropriate imaging and other diagnostic tests, or to refer patients to other professionals when necessary. Even in those jurisdictions in which DCs have diagnostic rights, financial obstacles are in place, such as the Medicare policy in the US that requires patients to pay out-of-pocket for imaging and other special tests when ordered by a DC [33]. While in some areas legislation has enabled patients to directly access a PT without referral, often referred to as “direct access”, this is often undermined by payer policies that do not cover PT services without referral from a medical doctor.

Modernization of legal statutes, practice acts and payer policies is needed to keep up with necessary changes in the delivery of value-based spine care, and to allow professionals to function “at the top of their license” [24].

Incentivizing value in spine care

The Accountable Care Organization movement in the US, which is designed to “manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population” [34], has grown considerably. This has provided channels for the novel implementation of primary spine care services [21, 23]. Further, greater calls have been made both within and outside the US for more efficient and cost-effective primary-level spine care [5, 6, 35, 36].

But significant barriers remain. First, it is common to encounter a “top-heavy” environment in spine care in which systems are incentivized to focus on high-cost and often low-value services [37]. Second, the relatively low—or completely absent—reimbursements made by payers to DCs and PTs, along with high co-payments, create significant barriers to the full implementation of PSP services. Health care systems in a fee-for-service environment typically derive substantially greater income from high-cost, invasive procedures than from low-cost, minimally invasive services, regardless of the benefit to individuals and to society.

Third, specific barriers to accessing DCs and PTs commonly exist [38]. For example, Medicare in the US provides coverage for only one service provided by a DC, i.e., spinal manipulation [33]. The financial responsibility falls on the patient for all other services necessary in providing primary spine care, such as physical examinations and supervised exercise. In addition, the care provided by a PT or DC often requires a series of sessions, the cost of which is partially or completely charged to the patient. Therefore, the total cost to the patient for visits to these practitioners can be substantially greater than the cost to see an interventionalist or surgeon. All of these barriers ironically create an incentive for patients to pursue care that is often inappropriate and of low-value [38]. Some efforts to remedy this situation have recently been instituted [39] but many more are needed.

Overcoming professional prejudice

A common assumption is that it is always necessary for patients with SRDs to first be seen by a medical doctor [40]. This assumption is not supported by evidence; when a patient with LBP sees a DC or PT as the first contact provider, greater value is realized in terms of clinical benefit, decreased cost to the system [41,42,43] and decreased opioid use [44]. There has been a shift in patient and professional attitudes toward acceptance of PTs and DCs as front-end managers of SRDs [45,46,47], but there is room for further progress. The PSP model seeks to expand beyond mere high-quality treatment to the application of primary care for patients with SRDs [16]. There is an opportunity to bring about open-mindedness regarding the role non-allopathic professionals (PSPs) can play in an evolving model of primary spine care.

Implementation and sustainability

There are two key barriers to implementation and sustainability of the PSP model. First, the majority of “spine centers” still focus on the use of secondary-level spine specialists, as opposed to primary-level practitioners, at the front end of care [48]. Second, many hospitals and medical groups are invested in a low-value environment that rewards them for providing more care, not necessarily better care [37]. These barriers inhibit health systems from hiring PTs and DCs to serve in the PSP role in providing high-value spine care.

However, increased demand for ‘thinking outside the box” is seen from multiple stakeholders involved in—or affected by—spine care, which has facilitated a greater appreciation for new and innovative approaches to SRDs [36]. This has led to several innovative ways in which the PSP model has been implemented, including in primary care [49, 50], hospital systems [21, 51], a payer system [23] and underserved communities [52]. Table 1 lists several of these successful applications of primary spine care in different clinical environments.

Table 1 Examples of environments in which the primary spine practitioner model is in place. This is not necessarily a complete list
Full size table

The Global Spine Care Initiative [7] and the Lancet series “Low Back Pain” [6, 53, 54] proposed a series of recommendations that respond to many of the obstacles to implementation. They laid out the problems in spine care [6, 55], and introduced world-wide initiatives designed to bring about greater efficiency and effectiveness, and to reduce the tremendous global burden of SRDs [7]. Among the several recommended solutions is a widespread focus on the application of primary care in the management of patients with SRDs, by professionals with appropriate knowledge and skill [35, 53]. This has brought significant attention to the need, not only for improved spine care at all levels, but specifically for effective, evidence-based primary spine care.

Future strategies for broader implementation of the PSP model

We envision broader implementation of the PSP model arising from several efforts, including:

  • Expanding PSP training from its relatively localized focus in the northeast of the US to other regions of North America and internationally, including an expanded use of online distance learning [27].

  • Shifting post-professional PSP training from didactic and workshop orientation to a clinical-based residency format.

  • Expanding the implementation of spine care pathways [56, 57] rooted in primary spine care, with the PSP playing a key role.

  • Entry-level professional programs, particularly in physical therapy and chiropractic medicine, placing greater focus on evidence-based spine care that prepares students for the PSP role.

  • Engaging and educating government agencies on the need for scope of practice expansions that allow the PSP to practice as an autonomous practitioner.

  • Promoting recognition, trust and acceptance among the general public regarding the PSP role of PTs and DCs serving as a first-contact professionals for SRDs.

  • Gathering further data on the impact of the primary spine care model in general, and the PSP role in particular, on patient outcomes, health care costs, system efficiencies and the “Quadruple Aim” [58]. One example of this is the recently-funded project by Goertz et al. [59].

  • Responding to the chaotic “Spine Supermarket” [60] environment by educating the public regarding self-directed decision-making in taking charge of their own spine health.

  • Expanding primary care practitioners’ awareness of the availability of PSPs, and the administrative and clinical benefits that arise from having a PSP in place on the primary care team [20, 49, 50].

  • Advocating for expanded changes in reimbursement designed to incentivize patients to pursue high-value primary spine care services [39].

  • Championing the role of PSPs as part of an effort to respond to the opioid crisis [61] by shifting emphasis away from pharmacologic to nonpharmacologic approaches.

  • Supporting and promoting the world-wide expansion of primary spine care in underserved populations through World Spine Care [52].

Conclusion

There is a need for innovative responses and solutions to the current inefficient, low-value situation in spine care. The PSP model is one such response. This emerging role in health care systems requires a cadre of professionals with the requisite knowledge and skill to bring greater efficiency, effectiveness and value to the management of patients with SRDs. In addition, it is essential for health care systems to be receptive to—and supportive of—this new innovative role.

The PSP model is growing, and has seen significant progress in development and implementation. However significant challenges remain. Further progress requires concerted and coordinated effort to accelerate the current pace. This necessitates stakeholder engagement, including the support of health care systems, payer groups, regulatory bodies and governmental agencies, and the continued participation of professionals involved in existing PSP environments. Improved care of patients, at decreased cost to society, is a genuine possibility, despite the recent problematic trend of disability and costs in spine care. The PSP role is a small but significant step in that direction.

Availability of data and materials

Not applicable.

Abbreviations

PSP:

Primary spine practitioner

SRDs:

Spine related disorders

US:

United States

PT:

Physical therapist or physiotherapist

DC:

Chiropractor

References

  1. Waddell G. Modern management of spinal disorders. J Manipulative Physiol Ther. 1995;18(9):590–6.

    CAS  PubMed  Google Scholar 

  2. Borkan J, Van Tulder M, Reis S, Schoene ML, Croft P, Hermoni D. Advances in the field of low back pain in primary care a report from the Fourth International Forum. Spine (Phila Pa 1976). 2002;27(5):E128–32.

    Article  Google Scholar 

  3. Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22(1):62–8.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med 2013.

  5. Hartvigsen J, Foster NE, Croft PR. We need to rethink front line care for back pain. BMJ. 2011;342:d3260.

    Article  PubMed  Google Scholar 

  6. Buchbinder R, van Tulder M, Oberg B, Costa LM, Woolf A, Schoene M, et al. Low back pain: a call for action. Lancet. 2018;391(10137):2384–8.

    Article  PubMed  Google Scholar 

  7. Haldeman S, Nordin M, Chou R, Cote P, Hurwitz EL, Johnson CD, et al. The global spine care initiative: world spine care executive summary on reducing spine-related disability in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):776–85.

    Article  PubMed  Google Scholar 

  8. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(6):968–74.

    Article  PubMed  Google Scholar 

  9. Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. The global burden of neck pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1309–15.

    Article  PubMed  Google Scholar 

  10. Dieleman JL, Cao J, Chapin A, Chen C, Li Z, Liu A, et al. US health care spending by payer and health condition, 1996–2016. JAMA. 2020;323(9):863–84.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Shipman SA, Sinsky CA. Expanding primary care capacity by reducing waste and improving the efficiency of care. Health Aff (Millwood). 2013;32(11):1990–7.

    Article  Google Scholar 

  12. Bernstein J, Garcia GH, Guevara JL, Mitchell GW. Progress report: the prevalence of required medical school instruction in musculoskeletal medicine at decade’s end. Clin Orthop Relat Res. 2011;469(3):895–7.

    Article  PubMed  Google Scholar 

  13. Wang T, Xiong G, Lu L, Bernstein J, Ladd A. Musculoskeletal education in medical schools: a survey in California and review of literature. Med Sci Educ. 2021;31(1):131–6.

    Article  PubMed  Google Scholar 

  14. Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CC, Chenot JF, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791–803.

    Article  PubMed  Google Scholar 

  15. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and metasynthesis of qualitative studies. Clin J Pain. 2016;32(9):800–16.

    Article  PubMed  Google Scholar 

  16. Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropr Man Therap. 2011;19(1):17.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Haldeman S. Assisting patients in their choice of treatment options: a primary goal of all spine care clinicians. Spine J. 2001;1(5):307–9.

    Article  CAS  PubMed  Google Scholar 

  18. Goertz CM, Weeks WB, Justice B, Haldeman S. A proposal to improve health-care value in spine care delivery: the primary spine practitioner. Spine J. 2017;17(10):1570–4.

    Article  PubMed  Google Scholar 

  19. Traeger AC, Buchbinder R, Elshaug AG, Croft PR, Maher CG. Care for low back pain: can health systems deliver? Bull World Health Organ. 2019;97(6):423–33.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Murphy DR. Primary spine care services: responding to runaway costs and disappointing outcomes in spine care. R I Med J. 2014;97(10):47–9.

    Google Scholar 

  21. Paskowski I, Schneider M, Stevans J, Ventura JM, Justice BD. A hospital-based standardized spine care pathway: report of a multidisciplinary, evidence-based process. J Manipulative Physiol Ther. 2011;34(2):98–106.

    Article  PubMed  Google Scholar 

  22. Zarrabian M, Bidos A, Fanti C, Young B, Drew B, Puskas D, et al. Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings. Can J Surg. 2017;60(5):342–8.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Weeks WB, Pike J, Donath J, Fiacco P, Justice BD. Conservative spine care pathway implementation is associated with reduced health care expenditures in a controlled, before-after observational study. J Gen Intern Med. 2019.

  24. Bogan M. Who Benefits from Moving Health Care from Volume to Value?: Institute for Healthcare Improvement; [cited 2021 16 April]. http://www.ihi.org/communities/blogs/who-benefits-from-moving-health-care-from-volume-to-value.

  25. Palmer College of Chiropractic. Identity Statement http://www.palmer.edu/about-us/identity/#Identity_Statement [cited 19 October 2021].

  26. Keiser University College of Chiropractic Medicine. Program Mission and Vision. https://www.keiseruniversity.edu/doctor-chiropractic-dc/ [cited 19 October 2021].

  27. What is a Primary Spine Practitioner (PSP)?: University of Pittsburgh; [cited 2021 16 April]. https://www.psp.pitt.edu/.

  28. Fordham B, Ji C, Hansen Z, Lall R, Lamb SE. Explaining how cognitive behavioral approaches work for low back pain: mediation analysis of the back skills training trial. Spine (Phila Pa 1976). 2017;42(17):E1031–9.

    Article  Google Scholar 

  29. McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol. 2014;69(2):178–87.

    Article  PubMed  Google Scholar 

  30. O’Halloran PD, Blackstock F, Shields N, Holland A, Iles R, Kingsley M, et al. Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis. Clin Rehabil. 2014;28(12):1159–71.

    Article  PubMed  Google Scholar 

  31. Institute of Medicine Committee on the Future Health Care Workforce for Older A. Retooling for an Aging America: Building the Health Care Workforce. Washington (DC): National Academies Press (US); 2008.

  32. Dower C, Moore J, Langelier M. It is time to restructure health professions scope-of-practice regulations to remove barriers to care. Health Aff (Millwood). 2013;32(11):1971–6.

    Article  Google Scholar 

  33. Medicare Chiropractic Services [cited 2021 16 April]. https://www.medicare.gov/coverage/chiropractic-services.

  34. Rittenhouse DR, Shortell SM, Fisher ES. Primary care and accountable care–two essential elements of delivery-system reform. N Engl J Med. 2009;361(24):2301–3.

    Article  CAS  PubMed  Google Scholar 

  35. Haldeman S, Johnson CD, Chou R, Nordin M, Cote P, Hurwitz EL, et al. The global spine care initiative: care pathway for people with spine-related concerns. Eur Spine J. 2018;27(Suppl 6):901–14.

    Article  PubMed  Google Scholar 

  36. Weeks WB, Ventura J, Justice B, Hsu E, Milstein A. Multistakeholder recommendations for improving value of spine care: key themes from a roundtable discussion at the 2015 NASS Annual Meeting. Spine J. 2016;16(7):801–4.

    Article  PubMed  Google Scholar 

  37. Mafi JN, Landon BE. Comparing use of low-value health care services among U.S. advanced practice clinicians and physicians. Ann Intern Med. 2017;166(1):77.

    Article  PubMed  Google Scholar 

  38. Carey K, Ameli O, Garrity B, Rothendler J, Cabral H, McDonough C, et al. Health insurance design and conservative therapy for low back pain. Am J Manag Care. 2019;25(6):e182–7.

    PubMed  Google Scholar 

  39. New UnitedHealthcare Benefit for Low Back Pain Helps Reduce Invasive Procedures and Address the Opioid Epidemic [cited 2021 16 April]. https://newsroom.uhc.com/news-releases/back-pain-program.html.

  40. Foster NE, Hartvigsen J, Croft PR. Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis. Arthritis Res Ther. 2012;14(1):205.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Fritz JM, Kim J, Dorius J. Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs. J Eval Clin Pract. 2015.

  42. Blanchette MA, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I. Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. J Occup Rehabil. 2016.

  43. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State. Spine (Phila Pa 1976). 2013;38(11):953–64.

    Article  Google Scholar 

  44. Azad TD, Vail D, Bentley J, Han SS, Suarez P, Varshneya K, et al. Initial provider specialty is associated with long-term opiate use in patients with newly diagnosed low back and lower extremity pain. Spine (Phila Pa 1976). 2019;44(3):211–8.

    Article  Google Scholar 

  45. Rempel J, Busse JW, Drew B, Reddy K, Cenic A, Kachur E, et al. Patients’ attitudes toward nonphysician screening of low back and low back related leg pain complaints referred for surgical assessment. Spine (Phila Pa 1976). 2017;42(5):E288–93.

    Article  Google Scholar 

  46. Penney LS, Ritenbaugh C, Elder C, Schneider J, Deyo RA, DeBar LL. Primary care physicians, acupuncture and chiropractic clinicians, and chronic pain patients: a qualitative analysis of communication and care coordination patterns. BMC Complement Altern Med. 2016;16:30.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Bowden BS, Ball L. Nurse practitioner and physician assistant students’ knowledge, attitudes, and perspectives of chiropractic. J Chiropr Educ. 2016;30(2):114–20.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Sheha ED, Iyer S. Spine centers of excellence: applications for the ambulatory care setting. J Spine Surg. 2019;5(S2):S133–8.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Kazal LA Jr, Whedon JM. Academic primary care clinic adopts new paradigm for first-line treatment of low back pain. J Altern Complement Med. 2021;27(3):282–4.

    Article  Google Scholar 

  50. Whedon JM, Toler AWJ, Bezdjian S, Goehl JM, Russell R, Kazal LA, et al. Implementation of the primary spine care model in a multi-clinician primary care setting: an observational cohort study. J Manipulative Physiol Ther. 2020.

  51. Allgeier M, Ventura JM, Murphy DR. Replication of a multidisciplinary hospital based clinical pathway for the management of low back pain. Spine J. 2016;15(10S):117S-S118.

    Google Scholar 

  52. Haldeman S, Nordin M, Outerbridge G, Hurwitz EL, Hondras M, Brady O, et al. Creating a sustainable model of spine care in underserved communities: the World Spine Care (WSC) charity. Spine J. 2015;15(11):2303–11.

    Article  PubMed  Google Scholar 

  53. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368–83.

    Article  PubMed  Google Scholar 

  54. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–67.

    Article  PubMed  Google Scholar 

  55. Hurwitz EL, Randhawa K, Yu H, Cote P, Haldeman S. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. Eur Spine J. 2018;27(Suppl 6):796–801.

    Article  PubMed  Google Scholar 

  56. Coeckelberghs E, Verbeke H, Desomer A, Jonckheer P, Fourney D, Willems P, et al. International comparative study of low back pain care pathways and analysis of key interventions. Eur Spine J. 2021.

  57. Fourney DR, Dettori JR, Hall H, Hartl R, McGirt MJ, Daubs MD. A systematic review of clinical pathways for lower back pain and introduction of the Saskatchewan Spine Pathway. Spine (Phila Pa 1976). 2011;36(21 Suppl):S164-71.

    Article  Google Scholar 

  58. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–6.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Goertz C. 1/2 IMPACt-LBP CCC 2021 [cited 2021 15 October]. https://reporter.nih.gov/project-details/10093277.

  60. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J. 2008;8(1):1–7.

    Article  PubMed  Google Scholar 

  61. Rummans TA, Burton MC, Dawson NL. How good intentions contributed to bad outcomes: the opioid crisis. Mayo Clin Proc. 2018;93(3):344–50.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

  1. Department of Family Medicine, Alpert Medical School of Brown University, 133 Dellwood Road, Cranston, RI, 02920, USA

    Donald R. Murphy

  2. Excellus BlueCross BlueShield, 165 Court Street, Rochester, NY, 14647, USA

    Brian Justice

  3. Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219-3130, USA

    Christopher G. Bise

  4. Department of Physical Therapy, University of Pittsburgh, Bridgeside Point Suite 228, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219-3130, USA

    Michael Timko

  5. Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 500, Pittsburgh, PA, 15219-3130, USA

    Joel M. Stevans & Michael J. Schneider

Authors
  1. Donald R. Murphy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brian Justice
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christopher G. Bise
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michael Timko
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joel M. Stevans
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael J. Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

DRM developed an initial draft and distributed it to the other authors. MSJ contributed to each section of the draft and BJ, CGB and MT added material in turn. JMS added material following the publication of two important studies with which he was involved, as well as edits to the remainder of the draft. After three rounds of circulation, DRM and MJS further revised the draft. The manuscript was then circulated again to each author, who provided further input. DRM then developed the final manuscript. All authors reviewed the final manuscript prior to submission.

Corresponding author

Correspondence to Michael J. Schneider.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

DRM, MJS, CGB, JMS and MT are involved in the University of Pittsburgh Primary Spine Practitioner certificate course. BJ is employed by Excellus BlueCross BlueShield, which provides health insurance in New York State. DRM and BJ are members of Spine Care Partners, LLC, a consulting company involved in implementing spine care pathways and Primary Spine Provider Network, LLC, a membership organization for primary spine practitioners. CGB is involved in the UPMC Center for Spine Health.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Murphy, D.R., Justice, B., Bise, C.G. et al. The primary spine practitioner as a new role in healthcare systems in North America. Chiropr Man Therap 30, 6 (2022). https://doi.org/10.1186/s12998-022-00414-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12998-022-00414-8

Keywords

Chiropractic & Manual Therapies

ISSN: 2045-709X